 Good morning everyone See our executive director is still in the house health care committee. We were asked to testify this morning I was lucky to go in and get my testimony done and escape quickly But Susan is still there. So there are a couple things that she would normally announce in the executive director's report Curious afternoon, but there are a few things I wanted to announce this morning number one, I think everyone's aware that Our general counsel Judy Hinkin left to take position of deputy commissioner at Corrections We're pleased to announce this morning that Mike Barber is the new general counsel who are not care board We're very blessed to have Mike's intellect and knowledge. He did a Incredibly great job running the all-pair model team for the last Almost here and We're just really thankful The other thing I wanted to announce is that on February 28th, we have an addition to the agenda Which will be a discussion on one care of Vermont 2018 budget order and grievance and approval summary And so that will be added to that agenda Next week we have another Agenda that's packed and we'll start in the morning talking about Stories being related back to the field as far as the actual implementation So that should be fascinating as well and Next Wednesday morning, we're also going to be joined unless they get called away or Other pressing issues by both the Senate Health and Welfare Committee and the House Healthcare Committee, so that should be a very interesting morning, so with that first item on our agenda is the Minutes Wednesday, January 30th. Is there a motion? So moved. It's been moved and seconded to approve the minutes of Wednesday, January 30th without any additions deletions or corrections. Is there any discussion? Seeing none All those in favor signify by saying aye. Aye. Any opposed? Those are approved Oh, let the record note that there were two abstentions due to absence So the vote was three zero two Okay, so at this point in time, I'm going to invite Pat Jones and her team down to to start to Walk us through a discussion on the 2020 So good morning Thank you very much. I Would like to have the opportunity to call on the team. I believe me I don't want to talk to them by making them sit up here, but you could go to a friend at any time Thank you so much So What we want to try and do today is walk through the draft fiscal year 2020 hospital budget guidance We'll talk about the process for how this draft of the guidance was developed I want to walk through a summary of the changes from the fiscal year 19 guys and that might be a little dry but They are really me and feel free to ask questions I want to talk about a proposal for April reporting from the hospitals as you'll see there's a couple of places where We are pulling Information and reporting requirements out of the budget process, but it's information that we still want to receive So we're recommending an April submission from the hospitals for those Walk through the draft appendices fairly quickly talk about next steps and then I Have a couple of slides because we have received a request from Gifford Medical Center for Modification to their fiscal year 19 Budget so that's the that's the way of the land so the process for developing the draft guidance for about the past Three months the Green Mountain care board staff and two of our board members have been meeting about every other week with a work group and We have Appreciated membership and participation from the hospitals. We've had a cross section of critical access hospitals and prospective payment system hospitals including the academic medical center The Vermont Association of hospitals and health systems has been there as well and the office of the health care advocate And we have a couple folks in the room here Who have been regular participants Julia Shaw? I see Chris Hickey just came in Mike del Trecato mark Stanislaus is here and Jack team and so I really want to thank them and the others who Participate in this process, and I especially want to thank the wonderful members of our hospital budget team Kessler Kelly and Perry for their incredible work as well. So we have heard you know input technical advice recommendations and the result of that As well as comments from individual members of the Green Mountain care board Resulting in the documents that you have for you today So I will start Through a summary of the changes from the fiscal year 19 guidance first of all there Have been a couple of changes in terminology. They're really clarifying the first is it Wherever we talk about net patient revenue now Are saying that patient revenue and fixed prospective payments, which are those payments the all-inclusive population based payments from the ACL So you'll see that acronym and that language throughout the document just to be clear that whenever we talk about NPR we really And then the other terminology we change we made is that we have referred to rate increases Increases or decreases to rates for commercial payers as well as Medicare or Medicaid Really the appropriate term is charge and so you'll see throughout the document that we reference charge instead of rate Just trying to get some precision there Beyond the change in terminology, I want to know that in the introduction that's a new section the introduction And it really outlines how the board will obtain information on quality improvement initiatives on Access to care and wait time information Community health needs and participation and Board member was recommended that introduction and What it really does is outline that we are still very interested in all of those things even though this is a budget process of the focuses primarily on financial Requirements and reporting Those areas still remain high on the board's priority list when reviewing hospital performance and then finally There are a few new accounts and definitions. We're just getting a little more granular on some of the assets and so We've added we will be adding accounts I think we already have having added accounts to our web-based software that allow Hospitals to report on restricted funded depreciation unrestricted funded depreciation Restricted other board doesn't made assets and unrestricted Doesn't made assets that helps us in terms of looking at Natrix like days cash on hand and so forth So just to note particularly most people won't care a lot about this but for the hospitals Just to know that there are some new accounts the next section in the guidance is The presentation requirements and this literally refers to what the hospitals are Asked to present at the budget hearings that we conduct in August So we've tried to standardize those presentations last year We had quite a bit in there And so the presentations were quite lengthy. We've tried to do some streamlining here and I just want to note that Just because these items some of these items have been removed from the presentations It doesn't mean that we aren't getting them in the narrative and that they aren't still important so things that we've added to the presentation requirements first of all Request up front that the hospitals know what their MPR fixed perspective payment Target rate of growth is for the fiscal year 20 budget and The changes and charges that we didn't know burglary state that last year So that wasn't always up front in the presentations So we're asking for that and then a second item that we are asking hospitals to add to their Presentations this year is an assessment of the hospital's financial health and we have a list of Financial health indicators and appendix for and we would like the hospitals to report on the area that are at in terms of those indicators and then finally In response to a comment from board member Pella We've just done a little definition on item number nine in the presentation requirements the long-range financial Outlook were to find that more specifically as a four to five year So that's what's been added to those Presentation requirements for August what's been removed and I want to know If it's removed it can still be highlighted by the hospital if it's considered to be an issue a risk or an opportunity We've removed the access wait time requirements. We've removed the hospital presenting on their response to the all-payer model quality measure results and We've removed the requirement that they present information on our community health needs Assessment update, but I will know that those are items that were expecting in the hospitals if the board concurs to report in April and the staff will summarize that and the board will have that information available for the budget hearings other things that we removed from Requiring hospitals present are the in-state versus out-of-state pair mix It's likely that hospitals for which that's a factor will highlight that as an issue Opportunity but we're not going to require that every hospital speak to that and then health reform progress and outcomes Well, that was required in the presentations and again This could be something that comes up as an issue risk or opportunity We're not going to require it in the presentations But as you'll see in the narrative section of the guidance there are a number of questions related to health care reform It's still very important us. We just don't need to feel that we need to require it in the presentations And I should know that when I say we You know, this is the staff's recommendation to the board on the first time the board has had a chance to talk about this is today Consider these recommendations the next section and probably the most robust section of the guidance is the narrative requirements and so you'll see that there are a number of Changes here We've added a number of items the first is that We are asking hospitals to explain When they talk about their budget to budget changes we're asking them to explain changes not only Between their fiscal year 19 approved budget and their fiscal year 20 approved budget But also changes over their full year fiscal year 19 Projections that's a recommendation from board member use of her And it just clarifies that we're really looking to see that change over projections as well we're asking for hospitals to explain changes and projections and they're operating margin and total margin as well We are asking them to summarize investments and routine repairs and replacements for a member lunch noted last year that that's a new statutory Requirement so we put that into the guidance we are asking them to complete a table About their participation in one care programs that really is Structuring data that we received last year when we could we tried to provide templates and sort of easier Structuring of data for the hot not only for the hospitals But for staff and the board to more easily review. So there's a table for that now We Board member homes Asked for the following two questions, which is first of all to indicate whether hospital employees are attributed to one care And that was a question that was asked last year during the hearings as well. And then also Describe to have the house described how they're changing their allocation of the resources to improve Population health. So those are two new questions and the health care reform Board member Pelham requested a table on reporting the amount of bad debt And that is really sort of a look back looking at fiscal year ended fiscal year 17 and then what happened in fiscal year 18 and that table can be found in the appendices We also received a comment from HCA the office of health care advocate asking That we weren't clearly state that the hospital should describe how Changes and charges are calculated and what the impact of those is on gross revenue by pay or tight and there's a structured table in the Epandesies that gets it some of that information as well. And then finally Board member Pelham asked That there be some information in there the required in hospitals to talk about how they address their cost shift And in fiscal year 18. So those are additions to the narrative There were some things that were removed again the community health needs assessment summary the patient access and wait times And the response to the all-pay or model quality measure results More proposing that those be removed but that hospitals report on them Using staff provided templates in April Men and health treatment capacity Information that was considered to be a one-time ask last year So that has been removed as a requirement for the narrative Similarly substance use disorder treatment capacity. However, I think we can assume that many hospitals will identify those two areas as areas of risk and challenge So we do expect to hear some information about those two items Healthcare reform investments. There was a spreadsheet that we had last year Asking hospitals to outline Their health care reform investments That really came about before Most of the hospitals were participating in the all-payer ACO model We now have 12 of the 14 hospitals participating in that model and as you'll see in a minute we also are recommending that there not be an extra Allowance for health care reform investments in the NPR growth target and that spreadsheet really supported that analysis And then there was a table that was in Last year's guidance. It was a table won't be looked at NPR drivers by hospital department and That was a challenge for hospitals to complete first of all second of all the dream out of care board Staff can generate a similar table based on information provided by the hospital So we are recommending the removal of that table sort of Grouping of requirements that are not in the narrative section. You may recall that last year there was a table asking hospitals to work on salaries by category by salary category and and that table is Has stayed pretty much the same we pulled out there was some some there was some benefits information around health insurance and retirement We pulled that out because the information that we were getting from that was really an allocation and it wasn't accurate and What we also do is add a couple of columns that calculate the percentages of staff and the percentages of salary that fall into each salary range But the inputs for the table are essentially the same We are asking for more detail on organizational structure This comes directly out of a recommendation from the office of the health care advocate It's something that we believe the board Would be interested in as well. We really want to we've got an Organizational charts in the past, but we feel like we could get more information What the relationships are between hospitals and they're related entities whether it's a parent organization subsidiary We felt like there could be a bit more information So you'll see more detail in that section and then board member Pell Also recommended that we get information on financial risk that may be present in some of those relationships So you'll see some additional detail in that section and then really Possibly the heart of the decision-making is in the budget guidelines Session that's where we lay out the NPR fixed perspective payment growth target and Right now you'll see that there's not a value in there But there are a couple of changes of note the first is that we are recommending that the board set a two-year NPR FPP growth target one of the things we heard pretty clearly during our work group meetings is that the hospitals are really doing their budgeting in the autumn for fiscal year 2020 and Having some predictability around what the NPR target for a great movie is is important and So we also, you know have a Five-year agreement with the federal government that takes us through 2022 that Outlines a total class of care or target. Those are two different things ones per capita In-state the others all revenue, but the idea of having some predictability really Made seem to make a lot of sense. So we are recommending a two-year Growth target and then the other thing is that we are at this point because most of the hospitals are participating squarely in healthcare reform Hospitals do some form of healthcare reform, but 12 of the 14 are participating in the all-payer model We are recommending that there just be a single NPR growth target and that Continue the health care reform investment allowance at this point in time. I do want to say that Ford member lunch Suggested that we have some language in here that first of all talks about our continued commitment and support of healthcare reform, but also That would allow the ward to revisit the 2021 Growth target if you ought to go with the two-year Two-year growth target in the event that something Significant changes in terms of hospital participation in the all-payer model. So you'll see that language in there There's also some language about What you know, we've had hospitals in recent years coming in below their approved budget You know, we are very focused right now on critical access financial health I'm really all hospitals financial health and so there's some language in there hospitals that come in below Budget so if the way it reads is that if hospitals have either fiscal year 18 Actual results and or fiscal year 19 projections that are at least two percent below the budget We would want to see their NPR limited To know more than five percent above their fiscal year 19 projections unless there's some justification we would want to see a clear explanation as some justification for growth that exceeded that and the reason for that is that You know budgets that are set too high Might not encourage the type of expense Containment that you hope to see in a situation where a hospital revenues are So so that's in the language as well and then There's a statement an overt statement that the board will in fact look at changes in charges Including commercial charges That's something the board is traditionally done the board Definitely did so last year And we want to just be clear that that is an area that the board will look at and then finally There's some language that the work group really weighed in on about aligning our efforts with the movement to value-based purchasing and the all-payer model and really Outlining that the goals are to support participation in the all-payer model to support financial sustainability of hospitals and to support affordable health care for managers In the enforcement section, so each year around this time we receive Year-end actuals information so right now the staff is working tirelessly on the fiscal year 18 year-end results and In the past when the board looks at enforcement The trigger has been hospitals that are 0.5% off Of their budget we got a lot of feedback that that's pretty rigorous like if a hospital is getting that close to their budget You know they're doing pretty well, so we are recommending changing that Sort of variants for looking at a hospital for enforcement purposes to one percent instead of zero point five percent and then board member Lodge asks that we You know put a statement in there saying that the Greenback care board one of the actions of the board can take if a hospital is over in this case it could really be over their budget We can require Hospitals to direct their funds for specific use to address the budget issue and an example of that is what you all did last year when The University of Vermont Medical Center was required to set aside funding for development of mental health and patient capacity And then under provider acquisitions and transfers not Major changes here, but we're linking to the forms rather than including them in the Document because they are a work in progress The team is doing some nice work on a consolidated forms and making them easier to Complete and then the statute was included in our guidance and we removed that because it's for the site and Summer eyes virtually verbatim so we didn't see to include the statutory language as well so that That is a quick tour of the changes In the guidance from the fiscal year 19 guidance. I do want to spend a moment before I walk through the appendices and talk about this proposal for April reporting So we've been developing templates in three areas hospital reactions to all their model quality measures and in particular And quality improvement initiatives that they're undertaking around those measures that our staff provides them with The latest regional or health service area results for as many of the measures as we can get data for and I want to be clear That it's not hospital results. It's health service area results, but we have a last year We obtained information from the hospitals on initiatives that they might have in some of those areas It was very helpful. So we'd like to continue to get that in April We also asked hospitals to report on access to care and specifically on late times for various specialty Surfaces that they might provide including primary care. And so we've developed a template for that as well and we'd like them to continue to report on Late times and then finally community health needs assessments We had some fairly extensive Information requests in last year's guidance But we can access hospitals, community health needs assessments and their implementation plans Easily on their websites in addition the Vermont Department of Health was doing some nice work on summarizing this So what we're asking for from hospitals For community health needs assessments is to outline what their community needs are that we're identified in that process When they're updating the report And information like that so it's a streamlined Information request, but we still want to get some information on the community health needs assessments So the idea is that we would like to get if the board concurs of this approach makes sense. We would like to get the Templates out to the hospitals by the end of this month and then ask them to submit the completed templates by the end of April So that would be well in advance of budget submissions and budget hearings in August and then the staff will Summarize those submissions and provide them to you so that you have that really important Contextual information in advance of the budget hearings in August so that you can You know explore some of that further with the hospitals It does a couple things one it gets you the information provides context to it allows the hospitals when they're Working on their July submissions to really focus on the financial That's required so So that's the proposal You know, I'll put out there that if the board Feels that it could blast that approach We could get the You know the templates out to the hospitals right away you have them in your packets They're posted on our website the work group Certainly saw that so I'll put that out there I don't know if that's something you want to do this week or maybe wait till next week But if we could get them out to the hospitals by the end of the month Give them a short time right and that the month will be over and week and a day I Think that it would be best if we Tried to make a decision today. Is there anyone on the board that objects to the bifurcation of the data as proposed Is there any member of the public that would like to make any comment or statement on the These bifurcated dates so seeing none Would you need a formal motion? Would a work member like to make a motion to Proceed with the proposal to Bifurcate the data and to have an able reporting for the quality improvement initiatives Access care wait times and any health needs assessment I'll move that we approve the proposal for April reporting as described by our chair and Is there discussion if not all those bearers signify by saying aye aye any opposed So let the record know if that was an endless vote Thank you very much and I want to especially thank Agatha for her work on those templates She's done quite a nice job Okay So there are ten appendices There's no change to appendix one Which talks about So that's the same appendix two is the verification on their own form there are two things here the first is that we Indicate that those should be completed by both the hospitals CEO and CFO, and then there is a placeholder the Board chair Lala in particular has Indicated a desire to have the hospitals chair And so we are in the process of Developing some language for such a note. So that's a placeholder Right now in this document and that should be forthcoming fairly soon Appendix three it has not changed. It's our exemption from public hospital budget hearings I will know that our recommendation this year is that there be no Exceptions from the budget hearings and fiscal year it's going to be fine I think folks realize that given the current environment that you would probably want to hear from all hospitals Appendix four is the list of financial health indicators that I Had mentioned before there are indicators related to profitability liquidity capital structure and costs and Mori has put together some benchmarks to that are associated with those financial health indicators So those are there for the hospitals to reference when developing their Presentation and particularly the aspect of financial health Appendix five I had mentioned previously. This is the structured table to obtain information from hospitals on their participation in health care reform and specifically on their participation in the one care program Appendix six All the bridges tables Where the tables that show the budget to budget in areas really some of the drivers of that variance I had mentioned before the old one being from that Which had really a hospital to partner type of love and the staff will be able to provide a table that That offers similar information The Seven is a Table I'm trying to understand a little more about what's happening with bad debt And again, this was a request from board member Pellum So it looks at the total bad debt at the end of fiscal year 17 What what positional bad debt is incurred during fiscal year 18? How much goes to collections during 18? How much was recovered from collections during 18? How much was written off during 18? And then what was the total bad debt at the end of fiscal year 18? So it's really a low back but an effort for the board to obtain information on What's happening in terms of that? And just you know for folks in the room might not be aware bad debt is considered Monies owned by the patients who appear to have ability to pay Appendix eight is a Structure table around the charge request So it looks at the request to change and charges by different categories of service of inpatient outpatient Professional services including primary care, specialty care skilled nursing facility if applicable And there's a row for other hospitals have other categories of service We're first looking for the request to change and charge and then we ask for what's the overall change in charge because hospitals Increase or decrease charges by different amounts Sometimes based on the category of service and then the remaining columns are really trying to get at what's the impact on the MPR So that would bring in contractual allowances. So a hospital may ask May request a certain charge But they may not receive that so this looks at What is the impact on MPR by pay-to-type and I think this gets it some of the questions that the office of health care advocate had as well Appendix nine is the revised salary table There's a total number of staff Calculated the same way as last year total salaries calculated the same way as last year And then the remaining two columns look at the percent of total staff in each of the salary Ranges and the percent of total salaries in each of the salary And then finally appendix ten is a placeholder for questions from the office of health care advocate you may recall that we provided those With the guidance last year and then it's helpful I think for the hospitals and for the HCA and so We are planning to do so again I have requested those questions from the HCA. So that helps the timeline for that I Thank you, so at this point You know open it up for discussion in terms of that steps Looking at a public time that period if any provisions are needed the guidance says can be made We do want to add that HCA questions to the appendices We need a board vote on a final draft no later than March 31st I think it's a statutory deadline to get the guidance out So what's it of length of public comment period are you suggesting? The office of the health care advocate requested 10 day, you know, I think somewhere To Do a couple weeks, so probably should go That's it could you already provide us support for the proposed April so I'll stop there And So the questions for that and the board Jess my only comment in fact you and I have talked a little about doesn't mean to go back and forth a little bit I'm really more interested in hearing as well from some of the board members on this topic First of all a big huge thank you because I do think that there's so many improvements in this budget guidance And I know so many stakeholders were involved and I'm really thrilled about some of the movements going forward But one of the things that I just wanted to bring up was we've integrated the all-pair model quality metrics into our process You know moving it to April with so part of our process the oversight of hospitals And something that I've been grappling with and we've been thinking about trying to figure out how to do this It's had to integrate the all-pair model financial metrics Into our process whether that be this year or in following years is something I think we need to think about these total cost of care growth rates Her capital so one thought I just had and I was gonna throw this out there was in much the same way that last year We put together that table of the all-pair model quality metrics for each HSA and simply asked the hospitals to respond to it You know their response to what they see happening in their hospital service area Another thing that potentially we get out is doing the same thing with total cost of care growth rates For the population of their HSA and then my parents simply asking the hospitals to respond again to That data It starts to move us aligning our budget process with some of the metrics We're gonna be held accountable for with the all-pair model So I don't know that you want to come by that or just the board members to have any response But I throw it out there Yeah, just that would be a good ad whether we can put an appendix, you know table in to capture that It's something that also I think we have the data and we can have we can Board has access to the actual data be more like putting a table together much the same way we do the all-pair model Quality metrics and just ask them to respond Whether they see happening in the cost of care Growth rates in their hospital service area recognizing that it's probably gonna be a resident level analysis and some of those Individuals living in that hospital service area may not be seeking to care at the local hospitals. I mean, there's a lot of caveats to That data analysis, but just a starting point. I think it'd be really interesting to Have the dialogue with the responses because basically You hear anecdotally a lot of why there are variations whether it's demographics for age Health factors like smoking or these any things like that. We also heard anecdotally from individual hospitals that way Higher than average total cost of care the Business that leaves their hospital to go to a tertiary hospital and that impacts their numbers So it would be interesting to see what the different each individual hospital does believe so I think it would be useful Hopefully it won't be too much work Just to make sure that time-wise and staffing wise they don't have I mean I have a lot of reporting coming up with the feds So I just didn't know Capacity wise what our capacity is I love the idea. I think it's a great idea. So that would be my only I think we need to get the feedback from our staff, but we also need to get feedback from hospitals One thing I will say that is I think this process that Coming forward with the guidance has been exemplary and it's a true work of collaboration where you work side-by-side That are regulated by us Worked in a way that to come up with better guidance That understands what the realities are for the regulated entities as well as we're us trying to make decisions Just reminds me of how sad I'm gonna be when we walk off the North Yeah Incredibly helpful and I'll again Phenomenal team that we have here That works day-to-day on the hospital budget process And you know to speak to four member homes is recommendation I think you know This the key point that you made is that the data that we get because we don't At this point have a CEO attribution for a good chunk of People who are in our own their claims database just in the same way that we do with the quality information just being really clear that these are Hospital results these are these are Geographic area results that you can't be considered to be That hospitals the total cost of care, but they're regional It's regionally that they could react to And I'm sure the David team would have some other Which is I also think there's been some great improvements in the hospital Guidance this year. I like the idea of a two-year NPR myself. I think it does provide stability and aligns well with Continuing to get everybody rowing in the same direction of the all-care model And I think it makes sense to spread out the reporting so that it's a little bit Easier on the hospitals in our staff in terms of collecting the quality data I think Pat made it did an excellent job of summarizing the concerns that I raised with her initially around that which are basically that When we're approaching the financial Components it has to be in a context of the triple A and the goals of the all-care model, which are not just financial having The financial results alone Without understanding the quality and the access issues to me are like I just don't think that way So especially given the way that we as a state are trying to approach healthcare reform So I guess I just wanted to emphasize that loud. I I think the submissions will be very financially Focused I for one will still be asking questions about the other stuff including participation in healthcare reform We get a good view from the ACO and the ACO budget process about how they think things are going in terms of Operational changes on the ground, but I found it very Interesting and informative to have the hospitals share with us how they're approaching their own operational changes because the reality is If we don't have everyone in the community rowing in the same direction and making changes in the at the community level The all-care model is not going to be successful So I just wanted to say that out loud so that there is an expectation How I'm going to approach questions over the summer Thank you very much Robin, and I want to follow up on your comments to say that I think this might be the time to Probably start a conversation that may take weeks to resolve but I just want to say that I Think that the clarity and certainty that a two-year Process will provide to the hospitals is going to be very welcome at this time in addition to the Financial struggles that rural hospitals are facing throughout a whole country And apparently throughout the whole world because there was a piece that Pat pointed out about Russia Just yesterday or the day before But with that Backdrop and the fact that these are critical years for our ability to achieve success to meet the Financial targets that are in the all-care model I would just throw out for an initial discussion for us to consider over the next few weeks that At least in my mind. I think it would make sense to have two years at the three point five percent level that mirrors What the financial target is in the all-care model? So that's just to start the discussion rolling and board members can come and ask they'd like Go ahead Robin I'm I'm Still kind of thinking about the target in terms of where I think we should land and obviously we don't have to land on anything today, but I also kind of like the symmetry there again as Pat said it's not the same Calculation and you know per person versus total But I think that it does Recognize that we that is the trajectory that we're trying as a state to move forward on and That it also allows for Hospitals to be thinking about really some critical changes that they're going to have to be thinking about in terms of moving from fee-for-serviced One of the factors that we're going to look at when we come up with this rate is some of the store code We're going to store three point five would be a bit higher than where we have been the past couple years So it's leads to consideration because we look at it I know it does tie into the total cost of care targets, but some of the we should consider as well And I appreciate that Actually to expand on why I'm thinking that we need to be higher than where we were at in the last two years is that as I Have been traveling with Pat and meeting with different hospitals around the state Just check in on financial solvency That has become increasingly clear is that supply demand equation for wages that the hospitals are facing is going to be severe over the next few years and When you look at the demand for higher salaries the lack of a supply of sufficient healthcare workers whether it be nurses doctors texts what have you Unfortunately, there may be a little bit of an arms race until There's actually a catch up by higher ed to be able to create more graduates and give them fields and I Don't I don't think that the next few years are going to be easy for anyone Seeing on a hospital board anyone sitting as a CEO or a CFO and There's going to be some hard decisions that are going to have to be made Just to deal with wages alone I'll just jump in here. I Think that I hear whatever you know, I agree with much of what I've been hearing I like the two-year predictability I think that I was in meetings where I heard some of the hospitals talking about how they did a bunch of Having some year to use some idea two years out We can expect really helpful in their planning. So I really like that idea And to your point Kevin I do think that the wage pressure that we're seeing in our state and nationally are really important to think about the workforce Shortages that we have the access to care issues that we see happening in our state Are going to be putting pressures on some of these hospitals and we have to recognize that the other Issue I think we have to think about is we're seeing rural hospitals struggling all over the country and We're asking our rural hospitals who are already struggling for many of the same reasons that other Hospitals are struggling. We're also asking them to change their delivery system And so I think to the extent that we can give them some headroom to be able to really change how they do their business Shifting resources away from the speaker service model towards this Value-based model. I think it's going to be important and they're going to be having to change their personnel and change their delivery system What they deliver to achieve population health goals. So I'm more comfortable perhaps than I would have been asked with at about 3.5 Like Jess, I think the two-year window is a good thing. I think it's Long enough to give hospitals to kind of do some more long-term planning as to where they are they want to be but it's short enough to You know that we have a recurring window to be able to address any issues. I I can't say I worry, but I wonder if for example we had a three and a half percent, you know growth rate that some hospitals Could use all of that easily given their pay or mix Rower that amount and other hospitals just don't have the capacity given their pair mix And so, you know, I've spent some time looking at the state budget You know the proposed budget and if you look at just the portion in Diva for To support a medical efforts It's less than a few tenths of a percent growth rate. And so if you were and I don't there is a relationship here I don't know how direct it is, but if you were in a Service area, you know like Springfield or Rattleboro You can have three and a half percent It doesn't be any good because you don't have the basin in your And we're serving to To make up for a Medicaid cost shift off other payers So I think we need to think that through but isn't that there's language in there that looks at what the Actuals are right and so to the extent that the actuals are well below what that what was projected The three and a half wouldn't necessarily apply right and there's language in there That suggests that we need that each hospital needs to be looking at what the projected Year-end actions are yeah, I don't ever want any hospital to think that This is a guaranteed We're gonna have percent increase on NPSR because somebody could ask for a 22 percent Charge increase to try to meet that and that's certainly would not be approved by this board, right? No, my point is I think there is a burden on us to be sensitive to that to that issue that if a hospital has a pair mix Where their major payer is flatlining them they can't even get to three and a half percent And and And I don't think we have a solution yet for that But it's something I think that we need to be aware of as we You know establish a three-and-a-half percent goal in your county can service that but You know on a springfield can't even You know, it's just wishful thinking to think that they can't and so you could have two hospitals Hypothetically the exact same cost structure and one can support that cost structure and one can't support that And I think that there has to be a lot of message said that we're not going to accept aspirational budgets And that has to stop I think and what I think we're going to have to consider and the guy is going to talk about in two year is If if a hospital either exceeds or misses in the first year, so if you start with a hundred and As you're as your actual when you come in at a hundred and five in the first year Then the expectation is you're gonna end up around a hundred and seven or so in the second year And or could be that's what we'll have to discuss rights versus if you came in 102 the first year are we allowing hundred and seven the next year? So I think it you know putting out a two-year target and people are looking to that You know, we're gonna have to give some guidance on some of the expectations because we know You know budget is is not where they actually come out and so everyone is always different They're either below or above so if you're dealing with a two year I think it helps with the predictability, but I also think it needs to be an understanding of if you exceed in that first year You don't shouldn't expect to get three and a half percent the next year If you miss there may be a reason why and I think Tom's point of how would you get there? Maybe you still could go but those are some things we'll have to consider as we do frame it But just to clarify we're not putting out a two-year budget target what we're putting out is What the guidance would be for the NPSR for each one of those years Over a two-year period to provide that certainty, but it's not a Component growth of 3.5 between year one and year three So I just want to make that Comments from the board. I just also wanted to say I really like the addition of the appendix trying to get clarity on the charges The changes in charges and how that impacts NPR and also how then the pair mix fees into All that because I think that that is In order for us to do our job trying to tie together our regulatory processes back to the rate review process Or we will have done the rate review process so forward from the rate review process I think it's it's hard to do that since we're comparing apples and oranges So I think that it may be very hopeful in terms of trying to continue our Our efforts to track the dollars through each of the regulatory processes So I just wanted to say thanks. I think that was some good thinking Actually, I'm not not a good thinking. I would also say the enforcement increasing the variance from point five to one percent I think that's a good idea. I think in your budget within point five percent is Pretty impressive in this world of changing the health care landscape. So I think a 1% Margin is probably more appropriate. So I appreciated that Yeah, there was just what I found clarify as we talked about The condition where the hospital Felt below in a year that they could potentially go up, you know, five percent the next year You know, that really was trying to look at we have several hospitals who have come in with budgets That was significantly higher a year over year to their where their actions were trending But we live in the budget guidance So we wanted to make sure that we were looking at that, you know, on the flip side of the hospital is coming in higher We're looking at containing costs and containing the VR So we would we did not put that in on the flip side to say they're coming in higher than you could also Expect to go up that higher amount. So that's why that's not in the guides because I know some of the hospitals were potentially looking to Include the other side of that and it really wasn't for that purpose. The purpose was to protect ourselves for those hospitals who are Underperforming to make sure we don't have aspirational budgets that could then Come to situations where they're losing a lot of money at the bottom line because they're not managing expenses To bring the top lines for the trend Tom I just like to say In high school my English teacher used to say less is more less is more You know, we're trying to write something and so I could tell that you've done a great job Along with Marines help in the staff because I know that if I put this year's guidance on the scale versus Prior your guidance on the scale yours would weigh less and therefore you've been working to the point Before we talk about Gifford is okay to open up to the public for comments on the guidance as presented Okay, great. We'll open up to the public for comments on the guidance as presented Julia A little bit of additional detail on what we do envision for the two Grow three, so I was a little confused by what a few different board members said so if it was 3.5 and then 3.5 Can you just explain how you envision that It would it be is it seven off of the current budget or is it no 3.5? So the following year we compounded another 3.5 percent off of what they were working from so It's not at least in my mind. It's not Year percentage setting the percentage for each of the two years So it'd be 3.5 This coming budget year Okay Even if they're falling short of that year You know that would be a compound so I think we need to look at how it's going to be executed and be cautious of how hospitals come in on the first year because if we approve them at a 3.5 and We're going budget to budget then they would be able to come in with a 3.5 the next year even if they fell short So it's it's going to be dependent on if a budget if someone comes in at one and a half Then the next year would be three and a half off that Okay, other comments from the public. Yes, Mark Stanislaus from the University of Vermont Health Network And you know just from our Vermont hospitals, we would like to draw sincere. Thank you to the Green Mountain care board and their staff Diva the HCA and our fellow colleagues Across the Vermont hospitals and also the board for allowing us to participate in these conversations I think they're productive conversations. I think we tried to find, you know You know shared solutions sometimes from different perspectives So I would just like to call out that thank you to everybody because at least from my perspective is participating them I certainly saw that throughout the process There is one item that we would like to have a better understanding from the board on this is a great opportunity On how we align, you know, two different processes that haven't really been aligned very very well And that's the historical Will budget review process and the all-payer model in the Green Mountain or And you know the ACL which is transitioning to a per patient payment model and in part of our Feedback, we'd hope there would be some recognition that if patients were changing around the state Or moving to different counties and that was the basis within that HSA That that population that was based and was attributed to those hospitals participating or hospital participating in those patients Acknowledging that we do only have one tertiary care hospital in the state of Vermont Which would be directly impacted by this also that this would be an opportunity For at least to open up the conversation a little bit more in the guidance to say if that was happening to allow the hospitals To come to the board and to engage in the conversation on how that might affect their rather than base So there is some interest to get the board's perspective on that thought Yeah, I can I mean it's it's an area of pretty great complexity needless to say looking at aligning the Financial metrics that are in the all-payer model, which is a per capita Total cost of care for Vermont residents with what we've historically looked at over time In terms of NPR Regardless of whether patients are in state or out of state not on a per capita, but rather on a total Total basis and you know, we've had some preliminary conversations around that You know, I think what mark is suggesting is that if We do see some movement whether it's in terms of attribution People who haven't gotten care starting to get care You know, I think the request is that there be an ability to look at that during the budget process I think I think that can happen without overt language I think, you know, the board should consider whether it wants to put a more definitive statement in the guidance As to whether that is something that you will look at But I don't think there's anything that precludes a hospital From coming and making its case and I would think you would want to say if there is movement of Patience or greater attribution Then that be brought out in the budget hearing process and in the submissions I think one of the challenges there is, you know, first of all, we kind of put on an NPR rate That's the same for the hospital, so that kind of starts the challenge But I think if the UVM network, since they're so large, if they were getting, you know, more Patients coming there and needed a higher NPR The challenge would be that where does it come out of which hospital? And so, you know, that we need to see some offset somewhere and you know, if you guys move up I'll make a big number half a percent that could be You know, two percent reduction out of that one other hospital if it's shifting So I think that's kind of the challenge. One of the challenges would be Where are they coming from and how do we make that offset somewhere else if we were to do what I think you're saying Which is maybe you're going to trend higher Well, I think all I'm saying is to allow some work in the guidance tool allows to the teams We know where the challenges are We know they don't perfectly align But to at least allow the opportunity to have that conversation So you will be allowed to have that conversation whether it's in the guidance or not Yeah, I mean to me that sounds like a risk slash opportunity related to health care for which I think we do want to hear about I think part of the reason why we had actually included the in-state out-of-state last year Which is a different issue, but it was in response to some of the Movement of care that we were seeing so just by analogy I think even without having the language in there to the extent that it's a risk or an opportunity for the hospital And related to health care reform I at least would definitely welcome the conversation Okay. Yes, first Yeah, just first of all, I want to reiterate what mark said about You know the the openness of the conversation we had I think it was very good and pat You know, I commend you and your team for all the work that you did on that. That was great Um, that's number one number two. I want to respond to The conversation about the two year And more specifically your comment about if we're one and a half one year Then there wouldn't be an expectation that you could go more than three and a half in the next I think the conversation we had about setting a multi-year target was to Not penalize hospitals for The potential of maybe an orthopedic surgeon that generates this a significant component of of revenue for You know, the hospital is not there one year. So instead of you only end up with the up percent and a half That the next year when that orthopedic surgeon is operating under full Capacity that maybe that next year has to be four and a half or five or whatever the number might happen to be So I think that multi-year gave the flexibility of sitting back and saying Either one way or the other you could be four and one year and three in the next or you could be two and a half and Three and a half or whatever the map works out to but it would allow that flexibility based on Maybe something that happens within your particular practice Or your particular organization as it relates to You know the physician compliment The third comment i'll make is in relationship to mark's point I think part of that is happening through the transfer opportunities you've given at least for our organization because You know, we keep pushing to say care should be provided locally no offense to uvm They they do what they need to do But I mean we continue to to provide services to our community that we think we should be provided in our community And sometimes that is a transfer From the network into the smaller community hospitals. We just added neurology as an example I were contracting with uvm to provide the neurologists, but again, it's a transfer of that Service from one service area to another service area, but and I think that's probably going to continue to happen For those services that should Occur within you know individual community So I think there is an opportunity through transfer to do that But I think there also has to be an opportunity through dialogue to understand that movement of patients Whether it be because of attributed lives or whether it's because of access to specialists I mean most of what's happened in our organization has been access to specialists over the last three years or so those three comments So I don't see any ads so maybe we should move on towards Gifford So, um, this is really uh, just teeing out the discussion But I think you're all aware that we have received a request It came in last week from the Gifford medical center And the request was for a fiscal year 19 budget modification They're asking for a 1.25 percent increase in the hospital's average charge And um, they're asking for an effective date of march 14th on that If if if the board were to grant that request and it were to take effect then They're estimating that a fiscal year 19 impact on mpr and fpp would be about $300,000 and the annualized uh increase would be estimated about $565,000 Are we convinced Do we have the information that would tell us that Insurers would honor every request on a mid-month date for example march 14th Yeah We we do not have information about whether the insurers would um would concur with that or not and I don't It may be set up that um, it's a percent of charge Um situation, but I'm not I'm not aware of that Uh, one of the requirements that we have is that the hospital's board authorized the request Giffords boards And so it it's january 24th meeting and I'll just note that in the letter That was received Requesting the modification Giffords cited workforce pressures in particular employee Survey feedback Indicating that um, they didn't feel their wages were market Levels They have not been able to provide an increase and then they also spoke to their Financial health Gifford has had some negative operating margins in recent years. They Have reduced costs But they said that despite those costs containment efforts They're still looking at negative operating margins. They also cited the hospital's age of plan which is above the average and The need to have some capital available for Addressing that as opposed to filling in the gaps and not negative margins I'll just Quickly show this slide last year For their fiscal year 19 budget. They came in with an fpr growth rate of minus 6.1 from their 18 budget The board Did not change That so approved that negative growth rate the total mpr was just shy of 56 million It's the commercial rate increase that it was uh, that was changed Gifford came in asking For a 4 percent commercial rate increase the board reduced that to 2.75 So a couple things at least that i would be looking for as we're doing the analysis number one, um consistent with the movement that we've seen in the proposed guidance for next year because gifford is a one of three in the contrary Along with spring field that Is a hospital owned by an f2hc like to see the financial information for the affiliated companies and how that impacts on gifford and Also, I think Would be helpful to have a corrective action plan given that, um again This is a case where npsr is not growing And that it really needs to be a plan that addresses expenses relative to the reality of the revenues and I would hope that We could ask for them to present us with a corrective action plan As we're looking at this Yeah, I would just add a couple things as well One would be I think if we put on this this was another one where if we looked at their actuals for 18 to where their projected 19 was coming in Um, I believe was an increase. It was just that fell so far short against their budget Whether or not they could provide us with a now an updated forecast Full year for the p&l and You know, I think for context to look at what their historical commercial rate increases have been and what their Budget to operating loss was for 18 because They came in quite Quite short when we look at their 18 budget to their 18 actuals I think at least showing the board their 18 budget to their 18 actual I'm not sure whether they'll be able to give us a 19 Kind of re forecast assuming they get this increase Because this I'm not even sure is going to put a bunch of a dent into where they came out. I think their loss In 18 was pretty significant And 19 may be trending there, you know as well Do not say no support this. I just think it's it's not even going to really solve their problems And to kevin's point really having a corrective action plan to how are they going to line up their expenses? with their revenue base You know assuming they get this Yeah, I will know that it looks like and I'm going to look to kelly here, but it looks like They are They experienced a net both a negative operating margin at total margin in fiscal year 18 Is that accurate kelly? And they and they were down quite significantly In their mpr budget to action So I'm just trying to wonder how this works In that I I don't in terms of kind of medicare rates and Medicaid rates I can't see them changing on march 14th even if we approved this so I'm just wondering what what the relationship here is to the pay of different payers And whether or not a giver has any sense that the commercial payers And self-insured payers are You know that this is a a viable path to follow So it's my understanding that they've researched their contracts with the commercial payers And their contracts allow for up to Certain percentage of this falls within it and they are confident that They will have higher reimbursement on the commercial site, but you're correct on the other payers. Okay. So I didn't know that so so We can inform that they're contractually the rate is A lot of the traditional margin I'm sorry. I didn't hear that Tom Tom's question was have we been informed that their existing contracts allow for An increase and I believe we have that but I'll leave it up to you. Okay. We'll verify that. Thank you Other questions or comments? Any comments from the public? Seeing none. Pat, did you have anything else you want to discuss this morning or? No I will just take a moment to thank all of you I'm not sure everyone in the room Is aware that I will be Departing And I'm taking a new position For me at at diva, but I I did want to thank all of you for the Incredible opportunity that you've given me over. I guess about the last five or six years. It's been A real pleasure. It's been incredible learning experience and I can't say enough as well about the staff That I've had the opportunity to work with so just thank you So actually we should be thanking you because We all benefited from Having had the opportunity to work with you And to see your work ethic to see your collaborative abilities To to see the way people want to work with you To see the smile on the face both of that beginning of the day and the end of the day Is something that we treasure And you will be missed greatly Thank you With that we are going to recess till one o'clock this afternoon. Thank you very much So welcome everyone we're going to get started and resume the meeting this morning And the next item on the agenda is the qualified health plan standard plan design and welcome Diva and weekly this afternoon and whenever you're ready take your way Great, so um, I'm just going to test the volume of this mic. It seems very strong Can everyone hear me? Okay Not enough they're moving back there Wonderful So my name is adi strumblow. I'm the health care director at the department of Vermont health access I'm just going to say a few words and then quickly turn it over to Dana to run through our presentation today So we are here obviously representing the department at this milestone in our annual qualified health plan certification process Specifically we will present the plan design proposals for the standard qhbs for your review and approval Daniel spent time talking through kind of how we got here, but I just wanted to Mention that we are very happy to be here. We had Quite the last few months waiting for the critical federal guidance that drives our development of the plan design And that was just issued several weeks ago So the fact that we're even here before you in february is a testament to a lot of hard work By the team and our partners at weekly and others. So Wanted to acknowledge that So I just wanted to flag a few items to kind of guide your review today It's a relatively routine year in terms of the plan design, but there are several factors that are influencing the proposal The first as always and as mentioned is the federal guidance. So specifically The actuarial value calculator that the federal government issues And that enables us to design compliant plans within federal parameters The second is the concept of silver loading, which you'll remember from last year. This is our second year coming to you with the reflective plans, which are In place to hold those customers who are not eligible for subsidies harmless from inflated premiums And Dana can walk through this again, but that's the premium is inflated to account for the loss of funding for the federal cost-sharing reduction program And then the third is state legislation. So Act seven in particular, which was passed very late last session or in the special session Mandate certain chiropractic and PT Co-payments. So you'll see that throughout the presentation today is another Factor in the plan design And then finally, I just wanted to mention I know it's very helpful for your review to see the enrollment data in terms of How many Vermonters are in each of these plans? We have to work closely with our Partners in the issuer community get that data We are very close, but we don't have it today We anticipate being able to share that by the end of the week and then we'll be able to Field questions on that when we come back to you next week. Great. So Dana, I'll turn it over to you Thank you. Good afternoon, everyone I'm doing the hand from diva. I just wanted to confirm that we have weekly on the phone or Julie Brittany and brook Julie them Brittany and brook are our own involved. Excellent. Welcome. Thanks for joining The buttons are right. Yeah, is it on? I think so It's making a real light I can just sit here and do slides So it's the button to the right Please provide some of an overview of our process And I'm going to frame up our recommendations and some of what's new for 2020 at that point. I'll then turn it over to weekly Consulting who will Lead us through the presentation of the three speeds by a metal level flatten down through Down through bronze and also highlight with some detail about what's new in the 2020 payment notice Calculated the effects are And then following that Questions and comments and discussion we can today And follow up next week again for review, I would refer you to this handout provided if you'd like to I want to just review what is Currently on the market that for my own effect for review today We have seven standard plans one for each Which means they're identical for each issues issue work. So 14 total One each at the platinum level one each at the gold level two That's silver and three each at bronze. So that's a little review today And also for your information, there are 12 man standard plans two gold Two silver two bronze and then one catastrophic plan each Here's a look at what our stakeholder group is comprised of There are three of us at least from diva representing plan management and the outreach not outreach and education area and our sister program Interesting and very valuable perspectives all of our issuers are closely involved staff from the department of financial regulation and Pre-mount care board and of course from the health care advocate We begin meeting in october each year and met regularly through last week So we have very spirited discussion supported by wiggly consulting to model the plan designs and we discussed through various factors that I'll Touch on again to come up with our proposal that you'll see today I can say that we Don't always have consensus for any decision that has to be made but I can say at the end of You know when it's decision time, we have common understanding and our proposal is well supported by a broad base Very quickly you want to just remind you of these Uh principles that we that we that guide our decision making we want Plans that are compliant. That's that's a basic and that Provide each of the essential health benefits. That's the most We value affordability with the limited levers that we have our decisions are balancing Uh premium things that are likely to drive a premium up or keep it as steady as possible as opposed to the member cost share those are the balancing Factors that we're always mindful of we value stability for each plan and for the market as a whole We try very hard to minimize large Benefit changes that are likely to impact premium or lead to something that's Hard for an enrollee to understand Obviously we want things that are plans that are attractive to new to existing enrollees and to new customers and then of course to actually use your plan if you Enrollees of all different ages and We emphasize Maintaining the lowest cost possible for primary care and behavioral health services Uh, you can't besides generic cost share wherever possible. Obviously no cost preventive services are required So here's a little bit about our approach Very basically as I said before we we try to Minimal increases in a strategic way balancing out that On the one hand something that may lead to a premium increase another being mindful of Enrolling cost share for when Someone actually needs to use their plan design innovations wherever possible again We don't we try not to implement anything and be disruptive to you Enrolling in a particular plan or to the market as a whole But if something looks attractive Consider it i'll give more detail about this Reposal to maximize AV as an example of that And then consumer education is always a very important factor. It was especially challenging in 2019 With the introduction of silver loading as important and valuable as that was it's important to help Our existing enrollees and new customers Understand what that's about how it impacts them and make sure that they're They understand their options switching now to the That proposal made for 2020 Maximum av for silver plans. This was introduced by the health care advocate In the fall we as a stakeholder group gave a very careful of their consideration The idea is that if we we wanted to maximize the av for silver plans on the exchange with the goal of by maximizing the av we intended to maximize the premium for the Silver plans on exchange which Results in higher benchmark plan premium. So that would benefit the Personally that would benefit the Subsidized the world needs with the assumption that again that A higher av would lead to the higher premium for benchmark and Off exchange we would be able to design plans corresponding plans off exchange to leave the unsubsidized customers So that was the basic idea Here's the summary of our our discussion Home stakeholders, it was a very strong and easy consensus around In support of maximizing the avtc for the subsidized population While at the same time wanting to protect the unsubsidized populations in silver plans Moving to our analysis that showed that Many of our we looked at both the for this in this case we looked at both on the Standard and non-statement silver plans many were already at within one percent of the maximum Which we which is interesting to look at We also found from our analysis that benefit difference would be significant between max av silver plan on exchange and the corresponding Lower av silver plan off exchange as an example A deductible could be one or two thousand dollars greater in the max av and then the lower av off exchange Which means it would be very difficult to say that that's the same plan Or that they're a reflective plan because many you know many of the Plans by name are identified by the underlying benefits. So something with a significant benefit difference Created that issue of well, what would you call that? stakeholders We're very concerned collectively About messaging with the experience of 2019 and explaining to Our customers the silver plans what reflective silver bent We're concerned with the prospect of having an even more confusing Market in this for silver plans if we had a reflective plan and something else Yet to be aimed with a lower av off exchange having too many silver plans was a was a real concern that it would be overwhelming the market Ultimately that has led us to decide that we would not go forward with that proposal and then as we were kind of Working towards the end of our analysis we learned in january that silver loading would be continuing through 2020 which has a significant benefits in the association That's where we landed we would consider that again in two or three years Very briefly as Eddie said The silver loading concept will be moving forward in 2020. It was new for a market in 2019 and the basic idea is that the on exchange silver plan premium will contain the incremental cost for the CSR program and then corresponding Premium for the off exchange silver plans would be lower. So in that In that way, we're not going to cause any harm In fact, we would benefit the unsubsidized population in silver plans by providing a lower premium silver plan there On exchange of an eligible In an eligible applicant or a rolly could choose a silver plan With CSR as if eligible or they can take that in BTC to another meta level Excuse me Off exchange again Silver plan customers would Select a reflective silver plan. There are no reflective silver plans on exchange and again the Benefit variation the minor variation is just a five dollar Co-payment difference of five percent pro insurance difference Now I should have included there a 25 dollar deductible difference for the high deductible health plans Applied to the ambulance or the emergency medical Transportation benefit And that was approved in 2019 and we proposed the same for 2020 and no impact on the other levels Do you want us to hold on questions to the end or I I mean, I think that's fine. Go ahead if you have any I'm just curious if you thought that If there's been any analysis on if the monitors Truly figured out The silver lining and they ended up in the right plan. Well, you thought the success rate was I think that will be a really great question for the next meeting when we can dig into the moment figures That will provide this week and then Should address that specific question next weekend among others So the information we get will definitely It'll show the event of they were in the right plan or not It'll show the migration from 2018 to 2019 Very good, everybody I'm happy to just give a sneak preview. I mean, I think we can safely say that there was not a hundred percent success rate Um, we found that for a number of reasons customers Some customers did choose to stay in silver plans on the exchange that had to increase premium We did some more Surveying them to see kind of what was driving that it was just a lack of understanding or there were actual reasons They wanted to stay on the exchange and we saw some of each So I think I think next week we'll have our Data and enrollment specialist Sean who can kind of speak to more of those efforts But just to give you a short answer It was not a hundred percent, but I think the message got out there And we'll be able to build on that next year Can you share now what some of the reasons might be for them to say? I think what we heard was kind of stability like the system hasn't been working great for a few years And now it's working well for me. Why would I why would I change that? And maybe a lack it gets very complicated in the The people who are eligible for the Vermont cost sharing reduction in silver plans and Depending on what you're what's driving those purchasing decisions. It's you know, um, just the deductible itself There could be people who even though it looks based on ap like people would be better off in a higher Gold plan people could choose to stay in silver. So we saw a lot of that that that was more complicated I think they anticipated And can I also ask a follow-up which is Did you another reason I could see that someone would stay on exchange even if they're unsubsidized Wouldn't be they own a small business They don't know what their income is going to be at the end of the year and if they buy off exchange They're no longer eligible for the apTC Should they be in the right income range? Do you think that? impacted any of the silver loading issues or do you think those folks Maybe you're a little more savvy and would have bought up if you can I mean that might be too precise an example No, I think that's a really good example. I can say that I don't think we Heard those stories in particular in our outreach, although the issuers are also doing outreach to the That population that doesn't receive subsidies But May be staying on exchange on purpose so that they can apply for the tax credit when they file our taxes And I think they I think that the issuers did early school across in particular did find that to be a message and they heard back So we want to very briefly Here's a high level view of the next steps in our Our annual cycle as Eddie said we're about a month later than we would normally present to you because of the delay in the release of the payment notice including the 2020 federal AB calculator that's essential to Our plan design, so We're making up time at the beginning of the process with a bit of a compressed timeline for Thank you DFR for compressing their time for for a form review issuers will submit their forms to dfr means a late march was a little bit later than the original timeline there We will explain more in a minute the payment notice And the irs limits payment notice is in draft form irs limits aren't Available yet those come from a different source expect them to be final in april then the rate process from submission in may through the Great review and public hearing And the decision in august that stays on track as there's the plan Diva will complete or is targeting to complete its plan certification which means formal selection of Specific QHPs to be offered on the exchange by the end of august for open enrollment to begin as we know November 1st So we these milestones are very Interconnected and locked in for Each kind of building towards preparation for open moment in November. Okay at this point. I'd like to turn it over to weekly consulting. I think Brittany will lead us through the slides I'm sure you can hear them and Brittany I'm sorry. That's okay. I just had a question before we jump into the the details of the plan design Um, can you remind us where things are legislatively with the bronze prescription drug maximum out of pocket? Because at one point I was time limited I've lost track of where that landed Yeah, do you want me to take that? Sure. Yeah, I should have mentioned that at the beginning with the other legislative changes so in the last session, um, we A bill was passed to make that indefinite So we have the ability to design bronze plans that don't include the maximum out of pocket for prescription under state law. Thank you Any other questions or Okay, um, Brittany, you'll just let me know what slide we're on. I'll drive it at this end Okay, great. Thanks. Can everybody hear me? Okay. Yes Um, so on slide 11, just a quick outline of Our agenda and what we're going to go through. So as Dana mentioned The first couple slides we're going to talk about are the proposed regulation changes for 2020 that are new compared to 2019 as well as changes in the federal actuarial value calculator for 2020 Um, and then we'll briefly talk through some notes and caveats. We have on our Um analysis and presentation. Um, and then we'll finally get into the the lead of the presentation walking through all of the recommended plan design changes So stepping through from platinum down to bronze Well, moving to slide 12, um, just a brief Couple notes on the changes from the 2019 Um Regulations to the 2020 draft notice of benefit and payment parameters One thing we'll mention again in the notes and caveats, but these are just draft regulations. The final regulations haven't been released yet But based on the draft the annual limitation on cost sharing is increasing to 8,200 from 7,900 in 2019 So this represents a $300 increase, which is smaller than the increase from 2018 to 2018, which was in around $550 But it's it's more in line with prior year changes to bridge between two and three hundred dollars a year One item I want to Point out also pay attention to is that the proposed limit of 8,200 is actually based on A new calculation that seems to determine the change each year There was a note that in the final regulations should the calculation refer Back to the old calculation that's been used in prior years This limit would actually be $8,000 rather than 8,200 So this will come up a couple times rather presentation because it's These regulations are draft and this is subject to change That should that 8,200 is go back down to 8,000 that will impact some of our plan designs and so we've made Notes of that throughout the presentation on which ones would be impacted and and our recommendations for handling that One other piece I want to know is that this limit does not apply to the high Health savings account eligible high deductible health plan that Maximum amount of pocket and there's a minimum deductible associated with those plans Is released by the irs? Usually in this room is usually released around the April so we do not have those Limits yet either Um The draft regulations Included some additional flexibility around pharmacy benefits. Um, so issuers can add a generic equivalent drugs and remove that associated brand drugs from their formulary in mid-year and along the bay Uh They can also accept certain brand drugs from counting towards the maximum out-of-pocket limit only when there's a generic available And only the generic equivalent amount would count towards the out-of-pocket maximum as well as accepting drug manufacturer response for Specific brand drugs that have a generic equivalent from counting towards the out-of-pocket maximum So each of these regulations are really geared towards trying to Encourage consumers to use the generic equivalent When it's available versus the brand equivalent and trying to control some of those pharmacy costs The other item we wanted to mention here in terms of changes to the regulations is silver loading As Dana mentioned silver loading will continue through 2020 but Health and human services are seeking comments. They specifically mentioned that in the draft regulation On whether to continue silver loading or how to address that in future years. So any changes Could play take place as soon as 2021, but they won't be in place for 2020 And there's several other changes to the regulations We didn't list them out here These are the ones that kind of specifically applied to plan designs. Others could impact other areas Or plan designs, but not as directly So those are the ones that wanted to kind of draw attention to overview value calculator for anybody who New here in the past years. We just wanted to give a brief overview Society of the center for consumer information and in insurance oversight releases a new calculator each plan year And it's required that this model be used to determine the actual real value of the plan for determining compliance with the metal level The calculator has several different inputs for plan design teachers Including deductible out of pocket maximum member cost sharing for about plenty different service categories Where you can input either co-paying their co-assurance and indicate whether the deductible applied or not um It only includes about 20 different service categories. So there are Some service categories that are explicitly included in the calculator There are also some plain design features not supported by the actual real value calculator. It's really kind of a simple plan design tool so if the impact of any features that aren't supported by that ABC Are considered substantial an actuary can modify the inputs to either both closely resemble that plan design or to modify the results of the calculator To account for these features And this would require an actuarial certification documenting the development of that modification So there are a few plain designs that we do to make adjustments for outside of the calculator on the Vermont standard plan design It makes the silver and bronze plan design both the deductible and high deductible High deductible health plan designs um We also want to point out that the AB from the calculator is different from the price maybe used by carriers in order to Determine the premiums and changes premiums here over here So the federal calculator is based on summarize national data Whereas the carriers are likely going to use their own experience. It's likely going to be specific to experience in Vermont So that that experience underlying the calculator the data underlying the calculator will be different um, and then each carrier likely has its own model and methodology for Calculating that pricing is easy, but it's likely different than the actual real value calculator Um, and again some features and not all service categories are included in the abc So that's another way that the pricing maybe is the the actual real value produced by the abc could differ um So it's like 14 just talking through some of the changes to the federal calculator um there weren't significant changes and updates from 2019 to 20 to the 2020 draft calculator Overall the underlying data was not changed. Um, it has been changed. I think a couple years ago the risk left more recent experience Rather the CMS trended the data So from 2015, which is the the age here that was used for the experience to 2018 The medical claims were turned at a rate of 3.25 percent and 11 and a half percent for pharmacy claims From 2018 to 2019 some slightly different trend rates were used, slightly higher trend rates And then for 2019 to 2020 the medical trend of 6.1 percent so the increase in the medical trend and the 9.8 percent for pharmacies so a slightly lower increase Were applied to get to an estimate of the 2020 Claims experience. That's the underlying the calculator So even though there weren't significant changes to the calculator primarily in the trending of another year of data There's still going to be changes required to those standard standards for 2020 This is mostly due to the leveraging effect of trend so to the extent that the underlying data was trending from 2019 to 2020 And they like the deductible and out of pocket maximum are capped at the U.S. and 18 levels A, B, for use by the calculator full increase Inherently under that because of that leveraging effect. So there's still going to be changes required So on slide 15 Member Palam has a question So I'm looking on slide 14 at the phrase despite the flexibility for states to redefine their essential health benefits and I just want to make sure like I'm on track in understanding that my understanding is that CMS for for year 2020 and beyond has kind of expanded the opportunity for states to either borrow other states plans or borrow certain categories from other state plans or expand their own plan And my understanding was that Illinois for 2020 was the only state that did so But I'm wondering as as we look at our essential health benefits plan. Is there any consideration not for 2020 but for 2021? to kind of take a look at our essential benefits and See how they're working. See whether relative to each other. They're the best that we can do Brittany, maybe I'll just say the first response on that and then pass it back to you So I think certainly so all of the benchmark plans for each state are it's public information It would be extremely easy for us to review all of it. I mean, I think as you know Board really has jurisdiction in that area that we've been very happy to support it, but When the changes were made federally, I think that we we talked in and In terms of diva, dfr, and agreement on care board about not not making a change when that flexibility was initially promulgated but We're certainly happy to support looking into that and we have contacts in all the states and we'll be able to access the benchmarks quite easily I mean, I asked that question because I think it goes through all 50 states actually and not with the five-tooth comb but Looking especially at some preventive measures where other states are I think a little ahead of us Then then then where we are But I but more generally I'm just wondering whether or not You know as we look at I mean, this is all still new to the extent whether we look at the essential benefits that we have Is there some process by which we say yes, so we've got to write balance or over time Are we looking at they might more full-time? And as certain adjustments by Yeah, I mean, I think we'd be really happy to engage in that conversation. I think we would Largely defer to you all so we should just talk about what that might look like in terms of the state process Yeah, I think any covered it. Oh one thing I won't say specific to the abc The data underlying In the I actually have a follow-up question not on the EHB, but on the differences between the federal calculator And I this may not be an answerable question So feel free to tell me it's not but I was curious if there's any way to kind of generalize how The federal data The federal data being in the abc Might either be a good or a bad thing for a state like vermont Where we probably have had higher mandated benefits over the years and may have Uh higher costs and other states for various reasons and how sort of those two differences interplayed between the premiums which would be based on the state data and the federal ab calculator And that may be something that's not answerable without us actually looking at the the data because of course, I know Hopefully you're not Engaged in our rate review process and may not be as familiar with our state data in this area Yeah, I think that might enter um, so we haven't adjusted the results of the abc output for chiral services and past years and don't see A reason to change that approach for 2020. So we continue to not make any adjustments for these changes in the chiral-reactive co-pay for 2020 For physical therapy co-pays, um, there was no um impact to the 2019 same design for act 7. Um, and so in 2019 these co-pays are aligned with the specialist co-pay consistent prior years For 2020 the same 125 to 150 percent of the ppt co-pay limit is applicable for physical therapy um, so similar to terra practice we said the physical therapy co-pay is equal to 150 around the down to the nearest $5 increment um, physical therapy is a service that's included in the actuarial value calculator So the ab presented on the following slide to reflect this um, this change and in most cases a reduction to the physical therapy um, co-pay And that's just as part of the Calculator is one of the services included for those changes are reflected So slide 16 a couple notes in caveats. Um, I think most of these we kind of touched on so far But we just want to point out so the 2020 regulation federal calculator are still in draft format There could be changes in the final versions that could impact the actuarial values and therefore the resulting plan designs Comments on the draft regulations reduced February 19th. Um, and I think typically they look at 60 to 90 days To review those comments So based on that timing it's possible the final regulations the calculator may not be really simple a role this year The annual limitation on cost sharing in the 2020 draft regulations as I mentioned before it was increased to $8,200 for 2020 However, should the final regulation refer back to the old calculation For that limit the limit would be $8,000 um The federal hdhp minimum deductible and out-of-pocket maximum limits are not yet released for 2020 So in 2019 these limits were 13 50 and 67 50 respectively um, so proposed plan designs do not currently account for changes in either the minimum deductible or out-of-pocket maximum So should the final limit for the deductible increase The farm would be deductible for the high deductible health plans will need to be adjusted So typically the minimum deductible increases $50 about every two to three years And the last increase for it was for the 2018 plan year So it may or may not increase this year. It's hard to say Any out-of-pocket maximum typically increases about a hundred dollars each year So should the out-of-pocket maximum increase um From 2019 2020, um, we basically kept everything in line with this 2019 limit Wouldn't need to make additional changes to reflect that out-of-pocket maximum In size 17, um, the estimated premium impact image that we showed a premium impact from the following slide These changes are meant to illustrate the trade-off between premium increases and the cost sharing increases To date this point trying to balance those two two pieces The actual premium change is going to be based on the carrier's models and their experience The premium impact that we're showing is based on a weekly benefit model And so if there's likely different methodologies, it's definitely different data underlying those calculations, especially with the carrier will use to ultimately determine the premium for page 20 um so we didn't adjust um, the weekly benefit model outputs for any Benefits designs that aren't incorporated in the model are accommodated by the model. Um, so for example the embedded um Drug out-of-pocket maximum on the height adjustable health plan again These are just meant to be kind of high-level estimates to illustrate The trade-off between those premium increases and the cost sharing increases and so they don't exactly align with what the final premium change is going to be these plans great Moving to slide 18 Here's kind of a first look at the results of the 2020 draft ABC That table at the bottom of the slide shows the plan each of the plans, but they're 2019 final Actuarial value was based on the federal ABC and was the 2020 draft result is And then on the right we show the acceptable range of AVs for these plans to meet the federal requirements so As you can see in this table the gold Silver and bronze deductible plans the bronze deductible with drug limited stands all are um Currently outside of the range just based on the 2019 plan designs and 2020 calculator. And so those three plans Do require changes this year to beat the divinements requirements One note on the silver plans that the cost sharing reduction Variation plan design will also require changes And those changes depend on the final silver plan designs. Um, they're tied to that that these silver plans Even if changes are not required to go for the platinum Run from deductible without the drug limit and the two hjp plans um We still Proposed changes to those plan designs In order to avoid, you know This av increase paying costs on for premium as well as to try and limit Some of the changes that might be required in future years And make, you know, small incremental changes each year versus No changes one year and then quite large changes the next One I have to know is that the accessible av ranges below have been adjusted for a fault for a couple plan design features That are not supported by the federal calculator We don't make specific adjustments for these For these design features rather we leave What we call the cushion in the Acceptable range in order to account for these designs So the first one is waiving the deductible for permanent prescription drugs This only applies to the hjp stands and we've allowed a 0.5 percent cushion So you can see the silver hjp plan has a high end of the range at 71 and a half percent versus 72 percent In prior years, we also made an additional adjustment to reflect That there is no cost sharing for basic pediatric oral health on the hd This adjustment was another 0.5 percent cushion on both the hjp plan and the bronze deductible plan with the drug limit This adjustment has been removed for 2020 As part of the stakeholder meeting the carriers reviewed the historical experience for these services and We estimated that the impact of this service To the av is not significant So based on that updated review of actual experience who actually removed that cushion so The bronze deductible plan with the drug limit for example The high end of the range is 62 percent this year whereas in prior years We estimated it to be at 61 and a half percent And so that gives us a little bit more room in terms of the plan design changes That are required this year I'm looking at this by 19 Sorry, is there a question? No, I was just saying that I don't see any Okay Um, just as a reminder, uh, there are certain thresholds Um for plan design changes That do not require um formal approval should the changes be below these thresholds. So On plan 18 we've just provided a summary of those those changes So co-pay changes less than or equal to 15 dollars Co-assurance changes less than or equal to five percentage points Devectible changes less than or equal to 200 dollars an out-of-pocket maximum changes that are less than or equal to the increase in the federal limit So for this last one for 2020 the proposed limit of 8200 versus 7900 last year So changes less than or equal to 300 would not require a formal approval As well as any modifications that are needed to be several guidance So in the following Uh by recommended and alternative plan defense that we're showing any changes from the 2019 plan design are shown they're shaded in orange and In boxes to try and highlight which which items actually changed from the 2019 plan design Any changes that also require word approval are shaded in green Just to highlight which ones are requiring Provided just a summary of the changes between the 2019 plan design and the proposed 2020 plan design We'll go through all these in a little bit more detail on the following slide So the pieces that I need to warm up now is that All of the plan designs except for the platinum deductible plan and sober heighted up to the health plan have changes that are above the thresholds that we just went through on the prior slide and would do require GNCB approval So then on slide 21 just a couple other items that we want to know So should the federal limit be finalized at eight thousand dollars rather than eighty two hundred? What we've shown as the recommended plan design has been embedded out of pocket maximum of eighty two hundred And this is tied to that federal limit. So should that limit reduce? We will reduce the embedded out of pocket maximum on the hdht plan to be eight thousand dollars But no other plan design changes are required should that happen For the wrong deductible plan with the pharmacy limit the recommended plan design Will not be the ab requirement with an eight thousand dollar out of pocket maximum We'll show that in a few slides, but right now it's set at an eight to two hundred dollar out of pocket max So in that case we're also requesting approval to move to the alternative design shouldn't be required based on that federal out of pocket maximum limit if it is finalized at eight thousand dollars rather than eighty two hundred And then again, we The formal approval is not required for out of pocket maximum changes less than or equal to the federal change So with the eighty two hundred dollar limit, this is a three hundred dollar change But it should that limit be reduced to eight thousand. It's only a one hundred dollar change Is the more of the out of pocket maximum changes? What actually required the formal approval? Then what we've shaded out no prior slide. So we're also requesting approval for those changes Um to the out of pocket maximum as we proposed here Regardless of whether the final federal change is one hundred dollars or three hundred dollars So those are all the pieces that we're really requesting approval for We can talk about it a little bit more if we look at the specific plan design But just to give you an overview of the items to be looking for it You guys briefly before we start getting into the actual plan design Yes, we're good. Let's hear you. Thank you. Yes, we're good. Great So amongst slide 22. So as I mentioned, we'll start with the platinum plan and move down to the bronze plan um each are Format we're going through the plan design is going to be similar for all the plans the first slide is the history of the plan designs from 2014 to 2019 And then we'll take a look at the recommended plan designs. Um, and then there's the third slide for each plan design that kind of talks through Our reasoning behind the recommended design and the changes we proposed So starting with the platinum plan, um there's been There really weren't any changes from 2014 to 2016 on the platinum plan design from 2017 to 2019 The deductible the medical deductible has increased um each year The out-of-the-pocket maximum for both the medical aid and the pharmacy limit has been increased a couple times And the specialist office visit and preferred grand copays were increased back to 2017 But we really haven't made any changes to the pct or generic copays or several of the Costary associated with different service categories 2020 recommended plan designs. Um on this slide the 2019 plan design is in the setting from the left column And then we show that our recommended plan design is an alternative design for each of these plans so As we noted before the platinum plan does not actually require any changes from the 2018 design it still needs to be Avere requirements under the 2020 draft calculator However, we are recommending several changes to the copays In order to limit the impact on premium As well as you mentioned trying to make you know smaller incremental changes Each year versus those changes and then larger changes required in future years So under the recommended design, we're recommending a $5 increase to the tcp copays A $10 increase to the specialist copays As well as a $5 increase to the generic copays Urging care and ambulance What we have done in past years and on prior and on the other metal levels is that Urging care The urgent care copay is equal to $10 greater than the specialist copay And the ambulance copay is $10 greater than the urgent care copay So we're Also recommending $10 increases to those services To maintain that relationship between those services and the specialist copays And then you'll also know kind of in the middle of this slide the chiropractic and physical therapy copays Um We have changed those to be a hundred and fifty percent of the tcp copay Um, and that's really those two services are the difference between the recommended design and the alternative design Um, act seven which we mentioned before and I think I forgot to point this piece out specifically but that act seven Only applied to silver and bronze plans um, so even though that Regulation does not necessarily apply to the platinum Through our our discussions, um, that we've been having The recommended design does apply that same retirement in order to maintain the consistency among the metal levels and Trying to you know Impact the making that consistency for consumers and reduce some of that confusion possibly between those differences of one of the metal levels and I moved just like 24 Yeah, the other the other piece on slide 24 that I did want to mention I kind of mentioned this when we're looking at the historical plans, but the tcp and generic pharmacy copays have Never been increased. Um, since the 2014 the first year the standards I designed for were in place. Um, so By doing the the five dollar increase this year it again kind of keeps being changed in the line with the other metal levels as well as will be There any comments or questions on the recommended design for the platinum deductible plan? It doesn't appear so I think we're all good So I'm moving this slide 25 We'll need to look at the gold deductible plan um Again looking at just the historical plan designs from 2014 through 2019. Um Similar with the platinum play a new changes were actually made to this design for 2016 The deductibles really only been raised once in 2017 And then there's been a couple changes to the out-of-pocket maximums as well um for this plane design Uh kind of similar to platinum with the tbt copay has never been increased. Um, we did increase the generic pharmacy copay in 2019 um And well it made some changes to the specialist office visit copay and preferred friend copay back in 2017 So the changes have been spread out across several different service categories Yeah, so on slide 26 um The 2020 recommended design Um proposes a $50 increase to the medical deductible so from $850 to $900 Um, it also includes a $300 increase to the medical out-of-pocket maximum Um a five dollar increase to the tbt copay Um, and then a $20 increase to the specialist office visit And again urging care and the ambulance co-pays are We've tied them to the specialist office visit to keep that relationship consistent. So So y'all are increases Again similar to the plasma plane design The terror plastic and physical therapy copay limits And the recommended design actually do not represent a change but that's Um really to keep the those co-pays at 150 percent of the tbt copay So again, even though act seven does not Um, apply to platinum and gold plans. Uh, the recommended design keeps that Does apply that limit in order to maintain consistency Um, one other item I want to know um, it is a large increase that we're Suggesting for the specialist copay $20 is quite a bit higher than some of the other changes to copay We've made in the past and on other metal levels The reason for that is looking at the plane design For all of the other metal levels that specialist copay is Two and a half to three times the tbt copay And so in order to maintain that relationship That's where the $20 Increase came We know that in that you know in 2018 it had the smallest ratio between the specialist Okay, tbt copay at just two times So again, that's $20 increase In terms of the relationship between the tbt and specialist copay I'm curious if anybody that diva has concerns about The kind of practical change given the legislative history They were trying to link it closer to our primary care I thought and this will Make it substantially different Well, it brings in the same proportion To this was right And it was it was thought to there would be a benefit to having consistently applied to each of the metal levels Even though it's not required for a platinum What would be helpful for me is to understand why x7 set it at the same level as primary care in 2019 But then allowed for the variation between 125 and 150 percent of primary care every 2020 If we know what the rationale or the thinking was My recollection is that it was deemed easier to just put it either at primary care or specialist by the issuers As opposed to coming up with some essentially third tier middle range So the timeline that we had to work on for 2019 as you know was so compressed So I think I think that that was kind of meant to be just like a transitional tool Bringing it down to the primary care level and then I think from a policy perspective the idea was it should not be linked to the specialist Co-pay and should be there should be some flexibility to keep it a little bit lower than that So, but I don't want to speak for the committees, but I think that that's what I remember from a legislative conversation Yeah, unfortunately, you know under the US there's probably a different ideas of why they did it I just remember some of their surat can try to make an argument that For many people kind of a practice for primary care providers So that's that's why I asked the question And I think one of the driving factors was that in these bronze I think it was just in the bronze plane But maybe in the silver having the co-pay at the specialist level was Leading to situations where the co-pay was actually more than the cost of the service It's particularly for follow-up services in the care of active care um, so that was I think in particular a particular concern to You know, obviously co-pay should be less than the actual underlying cost is Any other questions on the global design proposal? No Okay So moving this slide 28 looking at the silver deductible plan Again, this slide just provides the history of the reference plane Like the historical changes so the medical deductible and the out-of-pocket maximum has increased pretty consistently about each year Pharmacy deductible has increased a couple times as well as some changes to the VCP specialist co-pay And So the slide 29 looking at their recommended design It's made several different changes across Several service categories in the recommended design so increasing Both the medical and pharmacy deductible as well as the out-of-pocket maximum We also increased the CPP specialist co-pay And the co-insurance that applies to most facility services so in patient health patient free geology And again, the care practice is difficult their deco-paying fees are set at 150 of the PCP co-pay per Act seven So those are really Tied to the PCP co-pay and that's just for making there So you can see from 2019 to 2020 because of that limit a typical therapy co-pay is actually Decreasing 25 dollars So both the recommended and alternative plan designs are at the high end of the a view right each The 2019 plan design was actually at something 3.4 percent based on the 2020 calculator required about a one and a half percent production to The A&B in order to get it back in compliance with the actual value calculator And the difference between the recommended and the alternative design is really So in order to keep the co-insurance at 40 percent for inpatient health patient radiology Um, and it's been an additional increase in to the medical deductible and pharmacy deductible In order to to maintain that co-insurance of those they'll maintain the needy and the department I'd like to add here. There was a lot of stakeholder discussion around this plan. It was Back and forth. We were concerned about Raising those co-insurances for inpatient and outpatient and felt it was warranted to As a trade-off to keeping a lower deductible increase the deductible increases one of the main levers to bring down The av but we wanted to keep that increase as low as possible the other models that we looked at were considerably more than the four and 700 dollars you see here so When you were having a discussion around this in the stakeholder group Did you look at any examples or Other Kind of relativities between the the co-insurance and the out-of-pocket max So for example and for some inpatient stays at 50 co-insurance You'd probably hit your medical out-of-pocket max rather than pay the full 50 percent I was just curious if we have any sense of that like whether that would Be a rare. I mean, I know it depends on the inpatient stay So this is a hard thing to look at but just trying to get a sense of Like how often with a 50 co-insurance are people going to hit their out-of-pocket max Or do we think that most Common inpatient stays they'd still be paying less than that This is julia I think that's a short answer. We did not look at that this year I don't know how to set the path or the power of some of the plan design changes impact People with different benefits etc I do agree. We're looking at you know 50 co-insurance and it's really only, you know You know $47 between your deductible and your in your max model pocket, you know So you double that most inpatient state are going to You know to hit that amount You're saying a couple days your life is a hit it So we didn't look at that specifically, but I do agree that majority of patients they are likely to get the maximum But they likely pay to be paid a 50% for a very short period of time. Thank you Any other questions Let's move here. So Okay So On slide 31, uh, it's the silver high school health plan And it's a large piece of the medical vegetable Actually went down between 2015 and 15 and then back up. So The development will actually in 2019 at the same level it was back in 2014 Um, we've also made some incremental increases to the out-of-touching maximum and co-insurance of over the years so looking at the recommended plan design for 2020 This plan is another one of the plans that does not require changes In order to meet the limit. So we are recommending some incremental increases in order to again Small increases this year can help offset increases that might be required in future years as well as try to offset some of the premium impact from Just the leveraging effect. So our recommended plan design is an increase to the medical deductible From 1550 to 1700 As well as $100 increase to the medical out-of-pocket maximum Um, the alternative design also increased the generic and preferred brand uh, co-pay But had a smaller increase to the medical deductible Um, and so the recommended design it was helped was more important to keep being generic co-pay at the same level versus the $50 increase to the medical deductible And also looking I want to note here The box on the right, but we have reviewed both of these plan designs within an $8,000 embedded out-of-pocket maximum And both would continue to meet the AB requirements. So again, should the final regulation Have an annual limit at $8,000 That embedded out-of-pocket maximum would be would be lower but these plan designs Would continue to meet the requirements otherwise Should we move on or any questions please? Okay one bronze, I think Yeah, so I'm on I'm on site 34. Um, the bronze deductible plan with the pharmacy limit Again looking at the history for your reference the medical deductible and pharmacy deductible has been increased consistently throughout the years as well as the out-of-pocket maximum The co-pay was a large day of touch. There were a couple changes to the specialist co-pay with her brain co-pay, but Other than that, I was pretty much untouched Um, so looking at the 2020 recommended plan designs um We're increasing the medical deductible from $50,000 to $6,000 as well as the pharmacy deductible for $900 to $1,000 um, and the out-of-pocket maximum to the annual the draft limit of $8,200 Again, the chiropractic and physical therapy co-pays are being reduced to be 150 percent of the tcp co-pay or I should say chiropractic is increasing, physical therapy is decreasing That's required per act seven The alternative design made some additional changes to the medical deductible and pharmacy deductible And that's really in order to bring the out-of-pocket maximum down at $8,000 So under this plan design the recommended design does not Continue to meet the av requirement If the 8,200 needs to be reduced to 8,000 and so the alternative design um, it would be our recommendation designs to the final Regulations confirmed at $8,000 rather than $8,200 Can you remind us again of the timing of that final regulation? So as of right now the timing is somewhat unknown Our best estimate is sometime in April One of those final regulations will be released, but it could be Just any time around there Okay Thank you Any questions on this plan design? Don't see me Okay Sounds like we can move on to the next plan Yep Great Okay So the next plan is the bronze deductible plan without the pharmacy limit This plan is due in 2018, so we're really only have a couple years of historical designs associated with this plan So from 2018 to 2019, we've reached the deductible and out-of-pocket maximum For 2020, we're recommending some great interspecies To both this deductible and out-of-pocket maximum Again, as a demographic and physical therapy co-pays Are being changed in order to meet the requirements of Act 7 This plan design is another one that does not require changes in order to meet the AV requirements But again, we're recommending changes In order to offset from that immune impact The alternative plan design actually makes The only change to those overcrowded immune physical therapy limits That's required to meet Act 7 See no questions All right, we're down to the last plan design, the bronze deductible plan On slide 40 Again, kind of similar to the decision we made to the silver deductible plan Historically, the deductible and out-of-pocket maximums have increased relatively consistently As well as being embedded out-of-pocket maximums have increased each year to tie to the annual limitation Really simplify the risk So for the 2020 plan design, again, this one does not require changes in order to meet the AV requirements But we are recommending some changes to the deductible and out-of-pocket maximum in order to Help offset some of the premium impact The alternative design Only increases the out-of-pocket maximum in out-of-pocket medical deductibles So having slightly higher AV and slightly higher premium impact that's meant Again, similar to the silver high deductible plan, both plans have been run with the $8,000 out-of-pocket maximum And both would meet the AV requirements So we showed that embedded out-of-pocket maximums need to be reduced based on the final regulation Okay, so slide 43 and 44 We've actually seen already this is the summary of plan design changes So the changes to each design we're making as well as stating which ones require formal approval This is just to kind of remind everybody what those changes are And then 44 again mentioned the changes to the $8,000 out-of-pocket maximum Should the final regulation be reduced from say 200 in the draft regulation We've also provided some appendices starting on slide 46 But I just want to point out so these appendix aims that these are plan design changes And as we mentioned those are tied to the silver recommended plan designs Those changes don't require formal approval, but we've provided what those plans look like here for your reference The appendix B Contains the summary of all of the recommended plan designs for all of the different level of each You can see the progression from platinum to bronze From the platinum to bronze by side And then appendix B on the very last slide Includes the silver on and off exchange plan design So these are the on exchange and then the reflective silver off exchange plans So we don't need to go through those especially with the timing we have left But I just want to point out that those were in the back of the slide deck for your reference Super. Thank you. Any questions from the board? I just have a quick comment, which is thank you very much I know everybody's been scrambling with the lateness of the federal notice I did not Given the timing of when we got the slides last night I didn't actually thoroughly digest them before today because our meeting started at 10 So I may have some additional questions that I'll shoot I'll figure out with Susan who the right staff person to shoot those over And I'll just Great, but I would think if I'm assuming I'm probably not the only person on the board who didn't totally digest Presentation between five and ten So, um, maybe we can coordinate getting all our questions together and get them to you maybe by Friday so that You'll have a little time to prepare If we if we have others so that that would this is going to be my suggestion So Susan I'm assuming that uh, we've opened up a period of public comment on the right side Um, if it is an open at this time it will be by the time we get back to the office It will be open today, okay I think the challenge is The timing with the form filing in March Yeah, there's no question we would have liked to have gotten the information earlier, but it is what it is So I would suggest So at this time we'll open it up to any member of the public for any comments or questions. Yes, Dale I guess one would be Do not read after three o'clock in the afternoon if you want to sleep at night You want a disclaimer for future presentations And I heard you say what you said so Not after three Or maybe not until the weekend Okay There is such a thing as getting so expensive the quality doesn't matter Because the shock Will kill you anyways I actually had somebody on facebook that was describing this and it was It was the most horrible story to read But it was even more horrible when you realized it was true They had it stroke Then they had a heart attack And then they And they were posting their story as they went which I don't mind in this case I just want to say this was very respectful that they were sharing Because they were concerned about how fair it cost and Every step of the way you could see something positive happening as far as oh The miracle treatment it helped stroke wasn't as bad as it would have been The heart attack wasn't as bad as it would have been And then you would see a comment after that where it was like I just had another stroke. I got the bill. I think it's a big one And the whole thing just kept getting worse And what I realized as I read it is The shock of the cost made Totally error just not relevant What the quality was They they were buried for the rest of their life and they knew it and there was no way to recover So I was looking at the charts and I saw how it it has generally increased I've listened to the conversations over there In terms of we need more revenue This is going to go up and I'm trying to put this all on my head and not have it explode As far as get a general picture of how much cost Are we looking at that every single person is going to have as like a cumulative cost? And it's it's just a terror to look at it. It's like frankenstein isn't even Scary anymore I don't want to do this wages aren't going up Do people leave the state I I think that's not even a invalid Comment in the sense of do they start panicking and looking for someplace more affordable do they It's getting really scary as far as we're trying to do something better But it has a cost that's so high That better isn't the final statement. It's simply it's unaffordable I think you get to keep going affordability when you look at it What really scares me is that Even somebody with insurance Is going to be petrified to use it because of their out of pocket expenses. So Yeah, yep Walter Uh, I just want to back up the comment robin made and then that dale just made I just got forced off of my Medicaid and I'm now on these exchanges and I have prescriptions I have to Fulfill and all that I got a 50 cent raise at my job in the winter And that put me over the edge and I've been looking at all of this And wondering a as dale has said what will this cost in dollars and cents instead of per cents Because none of us understands percents The second problem is Is that how is this affordable for a vermonter for vermonters at all? This is not affordable. I too have seen those problems with people being Bankrupted by medical care even with insurance And I may be one of them now. I've already been through this before with the huge costs that you have even with insurance um So this You know all these cost raises really prove once again that market-based health care just does not work It may work for a few but it doesn't work for many And You know with someone that's just got to face this now am I going to have to stop the prescription because they're too bloody expensive Um, you know more treatments, you know, I need knee surgery. That's off until I get Medicare because you can't afford it You can't afford the deductibles So that's more a comment not a question but I wish people would put in instead of like 61.2 after a value put in the how much it is the Problem though this is that you have to look at what particular plan you have What your particular health experience is as far as medications and things like that So it's it's truly isn't individual calculation I haven't been able to do that yet. I just got picked off today You know, there's nothing that bothers me more than your stories of the benefit plus Somebody gets a 50 cent raise and they lose It's just terrible That's America That's kind of somewhat related. I I don't know we were ending the part of the conversation The plan since specific and I did have Want to ask Peebo a question Just uh that deals with affordability Okay So I You know the work that uh Sean Sheehan and Agatha did in terms of building that chart On affordability, which you know, it's these folks are indicating by the start that You can look at if you're 399 percent of federal poverty poverty level for the low cost plan We're looking at $150 a month premium And if you just go to the other side of that line at 401 percent of that level poverty level It's $852 a month And so So That is of concern to me It's also of concern that as you kind of climb up the ladder even to 500 percent of poverty There are folks that it's just not affordable as soon as you get across that line You're looking at 1340 percent just premium So I'm um and then Putting on my old hat. I went and looked at the appropriation recommendations for For the qhp assistance You know in the budget And we're looking at an increase from 2019 to 2020 from 8.1 Million dollars to about 0.22 million. It's a 1.2 percent increase And our per member per month basis is actually a three percent decrease So I'm I'm just worried that there are two worlds here That are heading in different directions and that things are getting worse before they get better and so I'm For me, I've never been able to solve a problem that I can't define and I'm just wondering if You folks at diva have spent some time trying to calculate what it might cost in additional subsidies To get people at the 9.8 percent threshold in terms of the percent of income for those between 400 percent of poverty and 500 percent of poverty as well as kind of You know looking for resources I mean does the silver loading that you did a great job in terms of the affordability of premiums But it didn't count everybody and So You know I listened to these I feel this And then I look at these increases going up and They are heading in different directions. I'm just looking for ways to begin to define What we might do to fix this problem because it is flexible. That's not a good idea, but it's flexible And it all depends on where we want to invest our resources and but It would just be helpful to have some visible measure of what it would take To keep affordability within that 9 percent range So that we can go after the solution I'll just briefly say we're very happy to help with modeling. I mean Expanding the not premium systems program is a legislative decision. So we just you know obviously we we are not the Many people at the table in that conversation, but very happy Yeah, I really appreciate the complications of it. You can't because of the weight or You know that that sets limits at 400 percent of poverty and the EPA is 200 percent, but I understand that But all that can be changed if you can't change it unless you kind of Put it out front center so people can really see the problem And in my experience, I found that once you can define the problem people are helpful to try to find a solution I think we very much agree and are quite focused on that issue of the unsepsidized population and affordability in that area Okay, are there other comments or questions from the public? Walter To back up tom's it was to make a good point If you it would it be a good idea to have somebody like myself or dale or Who's actually on these plans? of course to be part of that conversation or You made a really good point and i'm just trying to Back it up Well, I mean I I think at some point soon um Maybe the war to hold the meeting just on The deeper budget and and where resources are going You know just more more broadly. I'm going to get the The amount of money just for medical care overall And uh in the 2019 budget to the 669 million At the 2020 covers recommended 608 million dollars. So there's actually a decrease there. Yeah, which affects hospitals And this is where medicaid rates get built out of out of this budget But you know, you can look at some expenditure areas that At the close out of last year there was a 74 million dollars that kind of accrued from the snafus with my health connect largely And now that's being held as a reserve Wearing my old hat. I think that's a good thing And the state needs reserves, but maybe doesn't need all of it And the budget adjustment this year in terms of global commitment funds with the 24 million dollar increase If you look at the devious administration budget, it's gone up 34 million dollars in the last two or three years So there's money you can spend and maybe this is the way it has to be spent But maybe it isn't and I'm just kind of trying to weigh the equities here of folks that are In the situation like you are and other folks that I know That is there a different balance or are we just up with that? Yeah, I mean most I mean, I know so many people who just go without because they can't afford it Whether the millions of dollars it doesn't and the thing to remember is that when you talk in all those figures Which you're right. We pay them. We're the payers for all those things and I'm just People just look at me and they just they just say the heck with that. I can't afford it anymore And that's the real problem Yes, tail We're building up on your point This really bothers me Because the more it becomes an affordability issue and it becomes an acute affordability issue It's tax time where I get reminded every year That we're actually trying to go in the direction of people must have health care to try and make that mandatory um When I apply for certain benefits I have to turn in my income tax return To get the benefits which also shows that I have health care it's even got a Spiral effect where um If you don't do one thing everything unravels all the way down the spiral staircase so There's even more at risk here And I see that every tax season as an example if you Let's say you don't have health care You fill out your taxes So you have to fill out the taxes It's going to be listed as you don't have health care. You're going to get a penalty If you did get the penalty if we go that direction What happens down the road as far as everything else or what let's say the person decides I'm not going to fill out my taxes until the last minute, but they got other benefits that Are now going to be affected because they didn't apply Does that make sense it does but it's a legislative decision We're not going to decide whether there's a penalty or not here at the board So that proper discussion would really be over in the legislative committees Yeah Yeah, you're going to see numbers show up here in your charts. That's kind of reflect that If as a population issue, so yeah Yep, I just wanted to highlight that no did some message heard log clear any other public comment If not, I guess we want to thank our friends from diva and from wakely on the phone We've learned a lot We've tried to cram a lot into our heads in a short period of time and we need a little time to digest this information So we look forward to coming back to this next week and we will Try to get some responses to you by the end of this week Great. Thank you very much. Thank you So we're going to transition and uh Move on to a discussion with uvm about mental health So I thought I saw dr. Gome step in Who is leading the team? Okay And whenever you're ready to take it away, thank you very much. You hear me, okay? We can all right. Thank you I will chair the mullin members of the green mount care board on behalf of the uvm health network colleagues I want to thank you for the opportunity to provide the third quarterly update on our inpatient psychiatric planning project I'll start with an overview today. And then I'm going to hand it off to my colleague core director of strategic and business planning She's going to give you an update on the data analysis from our last update That'll be followed by eric miller our senior vice president in general counsel who will give you a little bit more detail on the IMD rights And then it'll be followed by robert paratini Chair of the department of psychiatry and co-chair with me on this project and I'll close out the presentation So again just to set the stage for what we're trying to achieve with this initiative Is to provide analysis engagement and planning necessary To achieve a desired Increate to design and create a uvm health network in patients psychiatric facility that will substantially improve access To inpatient mental health care is part of our integrated delivery system here in the state Again, we're trying to do this by designing creating a health network wide inpatient facility On the central medical center campus that will substantially improve access to inpatient mental health care We're trying to anchor all of this in a data-driven evidence-based process to the degree possible And most importantly to provide a forum for interested stakeholders so that you can provide input into the planning process And we have as we've mentioned in the past identified a team of stakeholders that meets quarterly the inpatient planning stakeholders group And that that group is ongoing at this point We're also trying to create opportunities to share the information publicly including public forums legislative briefings media relations, etc Again, just the outline of how this process is structured. We do have an overarching Steering committee that meets quarterly. We have a psychiatric inpatient capacity planning committee And then we have a stakeholder engagement through pips We are in completing the first phase of this project and we will be entering phase two And we'll be focusing more on the design and operational requirements So with that, I'm going to hand it over to Eve. That's going to give you a refresh on the data analytics Good afternoon I just wanted to go back to the current state This is the inventory of the number of adult inpatient psychiatric beds that we have available Around the state and this is a slight update from the slide that we presented to you Last time that we were here We have included that the numbers really haven't changed. There are still 137 general adult inpatient psychiatric beds But we did include 63 focused beds that are available At the Brattleboro retreat and at the VA and we thought Important to add those again to this list and this was included in our in our report So importantly of those 137 beds 45 are the level one designated beds and about 92 are General if you will inpatient for adult inpatient psychiatric needs And if you remember from our last presentation when we look at the number of those beds That are currently covered today under that IMD waiver. That number is about is 63 So it's very little less than 50 percent of all those general inpatient psychiatric beds Are covered under that IMD waiver today Our estimate of the number of additional adult inpatient Psychiatry beds that we need has stayed pretty stable At least this for this phase of the analysis So i'll remind you of how we got to that that final number of 29 to 35 additional beds We looked at those patients who received inpatient psychiatric treatment But had to wait in our eds for long lengths of time often Before they got that bed and so the five to nine bed component of that total estimate was the number of beds We needed to reduce delays for those patients who did receive inpatient psychiatric care But had to wait sometimes a long time to get to that bed So five to nine days Then the second component if you recall was using the most recent 12 months of actual data for patients in our eds Who came to our eds finding that segment of patients who would have Likely would have taken an inpatient bed had one been available and we called that the unmet need group And again if we modeled their arrival in the ed If you recall we looked at their length of stay and assumed that their length of stay was that lower cutie group We randomly selected from that distribution curve Long story short we came up with 18 to 20 beds for that unmet need group Um And then we looked at forecasted growth in inpatient In inpatient patient days from our intelligent partner sg2 And we came up with six additional beds that were needed and i'll remind you this This six beds reflected uh four percent a very modest four percent growth In inpatient days and that reflected sg2's Believe that we'll see an increase in shift in care from inpatient to outpatient That we'll see Reduced length of stay from new treatment modalities that will will come onto the scene and so on and so forth So that is the reason for the modest growth rate in contrast sg2's forecast for growth on the outpatient side is nine percent So you can see how that how that works there Just a quick Recap of what's going on and we mentioned last time that 80 percent of the patients who come to our inpatient psychiatric units Come through our eds So if we break down what's going on in the eds another way to look at this Is that unmet need group remember we went to great lengths to to say not everyone who comes to our eds Needs inpatient care. It's a it's a very small subset and If you recall what we did was we took all the patients who came from the That group of patients who stayed in the ed for 28 hours or more And one out of five who came from the 12 to 28 hour group that was backed by By some chart reviews and so on and so forth So that number of patients was 617 over the 12 month period But I wanted to emphasize that if you look at the number of patients who are coming to our eds with a psychiatric condition in the Um in the other part of the group that's four out of five in the 12 to 28 hour And all of the patients coming to our ed in the less than 12 hour group That um turns out to be about 10 000 visits over that same 12 month period You might recall that we modeled what the impact of having about 26 extra beds would have been On that group during the 12 month period had we had these beds around And what we saw across the state was about a 55 percent reduction in the number of patient hours for these patients in the eds finally we turned our attention recently to looking at Some of the assumptions that we used in our analysis and relaxing some of those And here's one slide that we shared with our pips group where we talked about what if we could decrease the length of Stay on average by one day for all of the patients that are in that unmet need group And what we found is if we On average reduce that length of stay by about one day We could decrease the need for For these additional beds by about one and a half to two beds. So very helpful But not um, you know, not a big driver in that that pretty large additional bed need number The other thing we did was we looked at and by the way, this length of stay adjustment would be either for You know improved treatment modalities But it also could be addressing some of the barrier Days issues, you know, when we looked at barrier days at the medical center What we found across that group of patients Was that there were some barrier days, but that barrier days again weren't a huge driver and In the additional bed need what we found over for the medical center was over the period of a year Reducing the barrier days that we saw Would have freed up two beds out of all the beds at the medical center Just defined barrier days. Oh sure Barrier days are the number of days between the the time that a patient Is ready for discharge Until the time that they are actually discharged You're welcome The other thing we looked at and let's we'll talk about for a minute is that those those IMD beds that They're at risk of of being lost You can think of that those IMD beds is really being a one for one either Addition to the number of additional beds that we would need So if we take away if if we lose a bed that's today covered under the IMD waiver It would add to the additional bed need So that's really a straight one for one That add All right, speaking of of IMD It's important to remember that the really great work that eve and her team have done Has been intended to identify the statewide Need for additional inpatient beds It hasn't been intended by itself to tell us how much of that need Should be met through new beds on the cbmc campus in order to do that We need to start taking account of a whole host of other factors But really high on that list of other factors is the sustainability not just of any new inpatient unit But the sustainability of cbmc as a community hospital And in order to assure sustainability, we need to make sure that we don't do anything That would jeopardize cbmc's ability to draw on federal funds For the treatment of its Medicaid eligible patient population That in turn leads us back to a deeper dive into the institution for mental disease or IMD Exclusion and so we'll take a few minutes to talk about that Let me start with the rule federal funding under Medicaid Isn't available for services provided to an adult inpatient at an institution for mental disease Now this so-called IMD exclusion has been baked into Medicaid since its inception in 1965 And in fact predates Medicaid in some other prior funding statutes And now decades later it's easy to lose track of why it's there It served a purpose that was laudable and important then and remains laudable and important now And that is it promotes parity and it disincentivizes institutionalization And that remains as important today as it was in 1965 But it also does something now that it did then which is it shifts the burden of the Paying for mental health care from the federal government to the states And that's the conundrum that we're dealing with right now You look at the rule and the first question you need to ask is okay. What's an IMD? So we've put that up here. It's a hospital or a nursing home With more than 16 beds that's primarily engaged in the treatment of people with mental disease Think Brattleboro retreat classic IMD think Vermont psychiatric care hospital in Vermont is the two biggest IMDs Obviously CVMC has more than 16 beds and that's going to remain the case for the foreseeable future So the thing that we need to focus on in determining the implications of this rule is What does it mean to be primarily engaged in the diagnosis treatment of care of folks with mental disease? And so it brought us up here to the test that is that is included in the state Medicaid manual What the state and ultimately CMS is going to ask is Is the overall character of a facility one that is of a Mental hospital as we would normally think of it And as only lawyers can in order to discern whether something is has the overall character of an IMD They have a five factor test Before we go through this five factor test. I want to make something really clear I believe that whether we added 17 beds 25 beds 32 beds The overall character of CVMC is very likely to remain one of an acute care Community hospital that looks a lot different than the Brattleboro retreat or Vermont psychiatric care hospital And if you look at the factors you can see why an IMD is typically licensed as a psychiatric facility Accredited as a psychiatric facility and is very often under the jurisdiction of the state like the pch's None of those things are true. At least is the regs to find them for CVMC But we still need to focus on these last two factors because our regulators do and because they have become important in the Decisional law that helps determine whether an institution is determined to be an IMD And we focus most closely on this question The last factor of whether or not more than 50 percent of the patients in the facility Are there for the treatment of mental illness Now in order to determine this you don't look at the number of beds that are designated for physical health versus mental health You don't even look at the average census of patients in the facility over a year Over a month over a week Instead the state and CMS will look at the number of patients in the hospital on the day The determination is being made as to whether or not the facility is an IMD And they look your denominator is the total number of inpatients Your numerator is the total number of inpatients there for psychiatric care And if you are above 50 percent you are at risk Of being determined to be an IMD when that factor is considered With all of the others that need to be taken into account when determining the overall character of the facility Now Eric can I ask a quick question? Is that uh, does that final factor come out of the case law or is that in the regs? That's in the regs Final factor is in the regs But I would say it's taken on outsized importance in some of the decisional law That might be because some of the others are kind of easy. It's check the box. Are you licensed? Are you accredited? This uh, is a little bit, uh Squishier a factor and as a result it's probably where the battle is joined and therefore where the The decisional law gets produced if that makes sense. Yeah, that makes sense Because you could certainly see that if you're talking about a smaller community-based hospital whose Census maybe varies quite a bit on the inpatient side Over time that what day you pick can start being key That's exactly right in a minute. We'll turn to cvmc and I'll give you some You'll get a really graphic illustration of how that can play out and even a medium-sized Hospital So There is nothing in the state medicaid manual that says how often it needs to be Determined there's nothing in the state medicaid manual that says that it has to be Every year every five years or that really provides any Additional significant guidance on for instance when the survey would take place When the determination would be made and As a practical matter, I think that this comes up so seldom At least in vermont where most of our institutions are very clearly an imd Or an acute care hospital that there hasn't been a robust Process built around it here or in many other states and so we don't have a lot of guidance on that to be honest with you Is there a reconsideration in an appeal process? So there is not a reconsideration an appeal process built into the regulations but in talking with folks who Think about these things for a living and represent clients who have to navigate these I do understand that very often if in the unlikely event in the unfortunate event They hit you on a bad day where your med medical surgical census was low and your inpatient psych Census was high As with many things cms related there may well be A period during which you can take corrective action in In an attempt to cure the problem in a sustainable way going forward, but again that's based on knowledge that is Not codified anywhere, but it's just gleaned from folks who practice in this area around the country I wanted to include the last bullet point here because It's easy to lose track of this The implications of being deemed an IMD are not simply that you lose federal Medicaid funding for the mental health care that you provide at the institution The consequences are that you lose federal funding through Medicaid Sorry for all of the care that you provide at the hospital You can no longer draw down federal funds for Medicaid eligible cardiac patients the hip fracture The pneumonia and you can see why as a result it is Of existential importance that we get this right with respect to the number of beds at cbmc So with all that background in mind, here's the question How many psychiatric beds when added to the 15 existing beds would put cbmc at risk of being deemed an IMD And as you can imagine, there are a whole bunch of factors that go into answering that question The easy ones are taking a look at the historical Census on the inpatient med surge and psych side and we'll look at that in a second the more difficult ones involve projections What is our medical surgical census likely to look like in the future? That's determined in part by some things that are beyond our control national and local trends regarding how And where care is delivered But it's also really important to keep in mind that it is based on some things that are within our control This board has already heard a little bit about the uvm health networks Care delivery optimization process through which we are trying to make sure that we deliver high quality care As close to patients homes as possible And so when we think with the numerator and more importantly the denominator of the IMD equation is going to be going forward We're thinking hard about our efforts to keep care local to keep care in our community hospitals like cbmc Where that's appropriate? We're also of course going to look at projections regarding inpatient psychiatric occupancy in the future And that depends on a whole bunch of factors Including how many beds are there in the system if there are fewer beds in the system Our occupancy rate of whatever beds we build is going to be higher If there are more we might be able to keep it at a more manageable level So we're trying to think about and model that as well Then of course we're thinking about whether or not if things got tight We do have the flexibility to take inpatient psychiatric beds offline for certain periods of time in the unlikely and And if med surge censuses fell in an unpredictable way or in a way that wasn't forecast And then not finally but last for our purposes when you're thinking about the number of beds This is distinct from IMD. You got to think about staffing efficiencies We all know that staffing a new unit is going to be one of the major challenges We face and doing it efficiently is an even greater challenge And what our facilities planners have told us is that With some exceptions eight bed increments promote staffing efficiency and therefore Help our ability to run this in a sustainable fashion going forward So does the architecture go into that? Absolutely and the architecture plays into it the programming of the beds in terms of the acuity of the patients who are being treated plays into it But all of those factors tend to converge on eight bed increments according to the folks at Hulsa that we're working with So when you take all of this and more in mind and begin to apply it to CVMC here is what you find CVMC is licensed for 122 beds But we know that what you're licensed for is not a terribly important part of the equation here They are staffed for an average daily census of 57 patients plus or minus and they flex up or they flex down as the census requires Really important to keep in mind that this is an average Anna noon and I were talking before we came in today and for the last several weeks Their census has been in the high 70s and low 80s virtually every single day And so 57 is the long-term average But over the last few weeks and months we've seen in patients patient censuses much much higher than that You see how that breaks down Of the 15 patient beds we have an average census of 12 to 13 Now you need to remember that some of those are semi private rooms and so 12 to 13 is very often An effective 100 capacity in those 15 beds given the treatment milieu and the needs of the patients And then a medical surgical census of 44 to 45 And if we were in a world where you could look at the average as you look at this and say 44 minus 12 you can build about 31 32 new beds without risking Flipping your your over the 50 percent mark. But because the the factors that we just discussed You can't do that Instead we need to look at is how these censuses fluctuate The bottom of the chart in the bottom the blue lines are the medical surgical census at CVMC for a period from 2014 to 2018 The red lines are the inpatient Psychiatry census during that same period And what you see is that while they both fluctuate a little the medical surgical census is much much bouncier over time And the inpatient psych is a little bit smoother over time And if I were to take this chart and kind of restate the challenge that's in front of us It's this How many more beds could we add without risking that the red line becomes taller than the blue line on nearly any given day over the course of the year And so we put that question to three different groups within the The three different experts within the group of folks who are helping us think about this problem First we had the folks from house our facilities planners Look at the question And they looked at historical data like this and they overlaid Different numbers of new beds basically lengthened the red lines by the uh by different increments 15 20 25 30 To see when the reds started getting taller than the blues Then we asked eve and her team including zack sullivan to do A miniature version of what we did for the needs analysis Which is build a computer simulation model that takes historical data And into which you can input different projections about the future And it produces a table of probabilities that on any given day at any number of new beds You're likely to spike over the 50 mark And then we asked a group from manette health Which is the lawyers and policy experts that have been helping us navigate the imd rules more generally To do an analysis based not just on the probabilities But on their experience with similar clients across the country And after taking all three of those analyses into account, we became quite comfortable With the conclusion that at cvmc we can add 25 new beds To the 15 existing beds and have an inpatient unit totaling 40 beds divisible by eight That will not create an appreciable risk that cvmc Will be deemed an imd Will not meet the entire unmet need in the state as identified by eve's analysis, which said we need 29 to 35 beds But that we think will still make a very important difference in cvmc's The uvm health networks and the state of vermont's ability to treat Our mental health patients who are currently not getting the care in the right place and right time And allow cvmc to meet its mission of serving both physical and mental health care needs of the central vermont population That's where we came down that that's what our these analyses have shown And i'm happy to answer any questions before turning it over to bob to talk about Programming considerations questions for eric That's a quick one. With this number of this 40, does that include you had a possibility of Taking some beds off line as the med surge unit came down. Is this assumption that these would be online all the time? This is the 25 new beds May depend on our Certainly depends on our ability to manage the med surge census and the inpatient Psychiatry census Whether or not it would require us to take beds offline depends in part on how successful We are in keeping the med surge census at the place. We believe it needs to be I think it's fair to say that if we build a 40 bed unit There may be points in time and the system will need to learn to Anticipate to this and we will need to learn how best to predict and react to this That we may need for short period of periods of time to say there's an empty bed But i'm sorry. We're not able to take that this patient at this time But that the periods during which that is true are so Small compared to the overall that this is a really this is the right decision and right trade-off To make in order to serve the most number of people most of the time Not that I am aware of Chairman mollett, um, I know that there are lots of folks working hard on this at Retreat at other places around the state We are in constant engagement with colleagues who Provide non-hospital based care to continue to try to maximize community and other services To either reduce lengths of stay or reduce the number of people who need inpatient care Um But I think we can anticipate that if we build something short of the number of beds Identified as the need that our occupancy rates within the beds that do get built will continue to remain pretty high But we'll still be able to make an appreciable difference on the way times and the lack of care currently Good afternoon We've reviewed the Analysis that tells us how many beds we ideally would build to reduce wait times And we've overlaid on that the imd restrictions that will limit us a bit to 25 additional beds And now the question becomes if we have 40 beds How do we program them? How do we configure them? To do the best job possible For our design goals, so we don't have the answers to these questions yet But we're entering the planning phase where we intend to answer When we intend to answer these and we have some design goals um, one of them obviously is That we want to reduce the wait time in the emergency department to no more than four hours For people who have had an assessment And have been determined to need inpatient care as the next level of care And that that is a major driver of our planning obviously We also want to build the beds and staff the beds in a way that maximizes our ability To manage any psychiatric or medical presentation that may come to the emergency department So we we want to have as broad a competence and capability as we possibly can We have to do this in an efficient cost-effective way So that it's sustainable And importantly we have to do it in a way that minimizes the risk of harm to other patients and staff And this this is an unpleasant reality that You know is it is hard to talk about but At vpch, it's a high rate of staff entry. This is a dangerous job at sometimes And our design has to take into account ways to minimize That harm to to anybody The initial process has been to look at ways that we would divide people by clinical characteristics into the Subunits that constitute workable units. These are units that are seldom larger than 16 beds And maybe are going to be an eight bed increments and maybe smaller than eight beds And just how would we divide? Is there a rational way to divide? We we looked at the The ways that this is done Had other places and in our places and we conclude that The way that most hospitals subdivide populations Correlates with measures of behavioral control Aggression violence and and risk to other patients and staff So we want to design the units to ensure the safe management And we want to maximize personal independence and freedom from restraint So we do not want a configuration that relies on seclusion or physical restraint or chemical restraint The design has to minimize that while ensuring safety And we want to if we have these behavioral categories, we want to decide how many beds are logically assigned to each behavioral category How many people do we have in these categories? And that would drive the number of beds we would build in each one when we looked at the The ways this is done nationally and regionally we weren't able to improve on what has evolved over many decades in vermont and elsewhere The basically stratifies people in a way that corresponds to the existing shepherds in three units The shepherds in six unit and what is now the vermont psychiatric care hospital So shepherds in three is a low security unit Shepherds in six can manage a degree of behavioral Discontrol and aggression and vpch is designed to manage any level of behavioral control and aggression CVMC just for reference is a mix of Of what is now at Shepherds in three and six and I think if they had had the opportunity to Configure architecturally they would have divided in a rational way But just because of the urgency of hospital demand They're accommodating what they can We divided uh, we we relabeled these Groups into a tier three tier two and tier one tier three corresponds to shep three tier two to shep six tier one to vpch And I just as a footnote want to acknowledge the comments from one of our Community participants who pointed out that Tier one can be a little confusing because we already have a nomenclature of level one that many people are familiar with And um level one is a is a term used by the department of mental health for its contracted units For a determination that more resources resources are needed for a particular patient So there's a different reimbursement for that care. It's it's a technical term that is a dmh term We want to make it clear that we're trying to Describe people clinically and not As a legal mechanism, but for all practical purposes if you're familiar with level one tier one and level one are basically the same thing so I I just Feel like I should explain that Because it came I got that feedback and I I don't want to the intention is not to confuse anyone the intention is to clarify We did two independent literature reviews. We did not find other stratification models in the literature and We do know that in Larger urban areas with many Psychiatry beds in large populations that units are configured in a specialized way They there may be geriatric units mood disorder units psychotic disorder units um And we uh, we don't think we have the luxury of creating that kind of subspecialized care because The next person who has a need for hospitalization may not fit where there is an empty bed In a specialized unit. So we are opting as a design goal To maximize our ability to care for any diagnosis Any associated medical problem within reason And to separate mainly by behavioral need It happens that the behavioral Characteristics of the patient correlate to the kinds of clinical program that we would use so Um, and I'm going to just point out the different the characteristics quickly of the different tiers um Tier one corresponding to vpch today or level one if you know that term um Are often psychotic disorders mainly a brain injury. They may have uh associated substance use problems or medical problems They have poor Commonly or as a tendency have poor behavior control They can be threatening. They can be violent. They can be aggressive They can have potential sexual aggression and very limited personal boundaries The tier two Is tends to be the same diagnostic categories But the behavioral discontrol is less the physical danger is less the uh, and uh It's a it's a lighter version of tier one And tier three tend to be uh People with depression personality disorder sometimes substance use disorders anxiety disorders associated commonly was with high suicide risk but There is not usually a behavioral dysregulation The patients are verbal They're able to work together in a group. Um, they can engage in treatment and conventional psychotherapeutic treatments and reflection and um, they are More easily able to associate together and work together in a therapeutic environment So the uh, you might now say well Why don't we just create the same level of security for all of these tiers and maximize the flexibility of the use of any beds And one simple, um answer to that is it is much more expensive to build A tier one bed than a tier three bed and most of our patients are tier three not tier one So we're going to have to struggle with the question of how to if we build 40 beds How many of them will be tier three? How many of them will be tier two? How many will be tier one and we we plan to that will be part of the process in the Phase two planning and we will engage others Uh in that conversation will engage stakeholders broadly to To look at that question We also are eager in the tier one and tier two To have mechanisms to separate aggressive patients. So It's not necessarily Necessary to create small units if there's a way to simply separate people who are in conflict and may May be aggressive with each other We don't have a way of actually measuring the number of people who are presenting with each tier But there are some correlational Characteristics that Zach Sullivan and Eve's group have used with us And we'll vet those data and use that to assign the the number of beds to each tier In this phase two We will begin in programming facilities programming process which also will lead and involves identifying every space needed the size of the space The contiguity of the space How spaces are associated in principle And that table of spaces and sizes Will be used by the architect later to actually configure a potential floor plan or space And we will have to integrate with the cdmc master facility plan to make sure that any planning that is done for the new Psychiatry and patient services that doesn't unduly Compromise future planning for other services at cbmc We'll begin looking at the financial impact including the capital needs and in the process of designing the The the programming for various units will have will be able to identify a staffing plan And the the financial cost of the actual operating cost I believe that's the end of my part and I'm happy to answer questions if I can So we are committed to the original timeline of three to four years for the full process We are still honestly articulating the key milestones Some phases have taken a little longer than we anticipated As an example the data analytics phase took a little longer than we anticipated We hope by the time we come to you for our next quarterly update that will be very synced with that timeline for you I haven't worked on projects. It's Usually you might have Things that take a little longer in one phase that might be able to expedite another phase So it would just be helpful to have some type of timelines that we can Actually try to anticipate what we might actually see in the finished product Understood Questions from the board Just to follow up to Kevin some so when you present this timeline that next time we meet Can you also have that kind of showing in the integration with the master facility plan so that we can get some sense as to whether They're trotting along at the same pace. Yes, that's the intent So we're trying to sync up our overall master facilities plan with this initiative And that we can't do one without the other and that we have to understand The most opportune location for this particular facility or unit So that's the intent is to bring those two pieces together. Absolutely Jess Every presentation is a concept closer to trying to help this problem that we have in the state, so I appreciate that My question actually is tying together the IMD and the programming I'm just wondering as you were talking about some of the programming we're wondering given the IMD concerns Would you be thinking about the replacement of patients with long lengths of stay right in cdmc That's going to reduce some of your flexibility to take patients online So i'm just wondering is that a fact Tier one tier two tier three bed placements in cdmc if you have or if there are more tier ones or more geriatric patients that are Harder to discharge Reduce some of your flexibility to balance the bed surgery And the site for the bed, so just wondering if that's part of the It will have to be the the In parallel to creating the new beds, we also have to address the patient flow issues and and there are some opportunities there You know, first of all, we have to do that anyway Because it's inefficient to keep people in a hospital who could be cared for in a less expensive and less intensive environment the Just coming back to a question that eric actually Answered and I thought I would add If we do replace the middle sex secure residential facility That will have a significant impact on the on our bed need Because we have calculated the number of beds needed Based on a status quo and the status quo is that there are people at vpch who are waiting in an acute care setting that is really designed for Assessment stabilization and other hospital functions who really could transition to a different place With a less intensive at least less intensive medical component so I see that as a ray of hope in the In the dilemma of trying to juggle the incoming need and the outgoing need But I think the bottom line is that we're going to have to keep paramount A flexibility because we don't know what the future brings And we're going to have to adapt to whatever happens today. Whatever happens in real time As patients are seeking hospitalization Thank you. I guess we'll open it up to the public for questions or comments Ken Yes, I think As a person who's participating some of the meetings I really have to say that This is a really strong team of working hard To figure out pieces of the puzzle And you know, it's like it One of the realities is when you have a good team You actually should expect more or not less And it's a weak team You kind of ah, well, whatever If you added dr. Ronsted to the group, it would be like a five person basketball team And they kind of have everything they have You know clinical expertise. They have legal expertise. They have very good administrative and communication skills And they're really being very thoughtful Which one will throw the elbows? We'll get to that I said they're good, but they're not perfect The the issue that I would raise is and I think the chair Picked up on this right away, so it was good You know, it gets There's a balance between being incredibly thoughtful and thorough And somehow not building in the reality that there's a crisis here and there's a sense of urgency You know, there are seven members of the sitting in frontier And representing different communities and in your communities over the next year you have people Going to your local emergency rooms and potentially Getting stuck there If it was pneumonia as somebody mentioned or it was heart disease or cancer The notion that you have folks sitting in the emergency room for days represents a true crisis and I think the one thing that this team doesn't have yet maybe Is speed Which is very important for a team to have and so I turn to the board and say Uh, perhaps some thought could be given as almost a one-year mark in this project is going to be reached To figuring out how to build speed in the time table Is just not acceptable in some ways to say well, it's going to be four years Because when you say it's going to be four years, it's going to be five years It's a little bit like in the legislative session, which many of you are familiar with Everything should get done In a timely fashion, but it's the last week of the session where 75 percent of work and decisions get So I hope that you really do put a focus on this question of timetable um, this is not This is not simply A project which is very important and a lot of good works getting done But there's a real crisis out there Which is frankly as people I think on the board have said it's a disgrace and to some degree You are the managers of this project and you either can build incentives into having speed in the project or disincentives and I just would ask you as the Year ends year one to figure out how to build in urgency and incentives And speed to move this project along even faster than it is because there's a real crisis out in the communities And it will only get worse in my opinion. Not better between the time Now and whenever the door is open on the new facility Thank you for those comments so I can I think everybody in the state was just it could magically Happen overnight we know that can't happen. I think that People are trying to do the best they can we we encourage I wouldn't say speed because we don't want any errors in speed But we encourage that it be accomplished as soon as possible with the best possible results so And I'm pretty sure that everybody That I'm looking at understands that dr. Bromstedt Yes, I'm speaking from the public perspective because I'm not up there and I actually agree 110 percent with mr. Liebertof the obvious counterbalance is The vermont way and the vermont culture which is to make sure That we engage people appropriately to kick the tires on this plan. I can guarantee you Even without a fifth member this team could go off and in a very short period of time Design what would be a really credible solution and Get shovel in the ground what we would lack in that is the kind of discourse and back and forth and Frankly important input into what this looks like So we've got to balance those two things Ken, but we're not going to take our foot off the gas pedal We're going to try and do that balancing act, but end up solving this crisis as quickly as we can Thank you, dr. Bromstedt Other yes in the back so I just want to acknowledge that in the planning process and I think john alluded to it There has been and have been considerable conversations with community partners in reaching some of the conclusions that they're reaching and Well, I think eric was alluding to the implications for the bed count based on IMD and whether we continue to get a IMD waiver and if there are other beds that drop off I think it's important to recognize that All of this calculus is predicated on having the strong community-based system That to the greatest extent possible Diverts individuals from coming into the bed In the first in a patient bed in the first instance and then having the capacity to take people out as quickly as possible so That's that's one point I want to make and I think that there's a been a clear acknowledgement on the part of the health network that this activity cannot exist in a vacuum And I expect that that impact is part of the active planning process that has taken place and will take place secondly, and I guess recognizing the that The network is in fact responding to the charge from the green mountain care board I want to acknowledge that they're basically answering the question that you ask but without Meaning to be disrespectful You've only asked half the question Because all of the patients that they are talking about are adults And the reality is that we have a significant problem with children who require psychiatric care and these beds are not Being talked about for children So just as an example on monday because that's the last state I have data for because we track And I work at the Howard center in chipmunk county. So we work with folks who are Involved in the activities that we've been discussing so on monday We have 17 patients waiting for an inpatient placement Five of those were adults in the er And two of those were adult children in the er But we have 10 children waiting in the community Because when children show up in the emergency room In crisis They're typically coming with a family member And the family member is acknowledging that they have reached their limit in terms of knowing how to deal with this psychiatric crisis But they're not kept there they're sent back home To wait until a placement can be found and i'm not blaming the hospital for that i'm just acknowledging that there is a tapped out resource i.e. families which are being asked to carry the burden Of caring for their psychiatrically challenged children that they've already acknowledged They don't have the capacity to do Because we have an inadequate amount of psychiatric inpatient beds for children And so I would ask the green mountain care board to keep that in your frame of mind As you're thinking about Conversations in your regulatory room going forward Thank you. It's an excellent point reminds me Of all the discussions that we had when I was on the education committee about Students who a lot of frustrated School of issues who didn't think that kids were getting the correct treatment fast enough And so I'm sure this is not just a burlington problem. It's a state-of-the-art problem One that's going to have to be addressed Any other questions or comments from the public? Seeing none. I want to thank the team and uh, I would bet on this basketball team any day Thank you Is there any old business to come before the board Seeing none is there any new business to come before the board? Seeing none is there a motion to adjourn It's been moved in second to adjourn all those in favor signify by saying aye. Aye. Any opposed? Thank you everyone. Have a great rest of the day