 Good afternoon and welcome to the Green Mountain Care Board. My name is Kevin Mullen, chair of the board, and we're about to get started. The first item on the agenda is the executive director's report, Susan Barrett. Hello, thank you, Chair Mullen. I have a few announcements. First of all, scheduling, we have added for next two weeks from today, February 24th. Our staff is going to give the board an overview of our 2020 annual report, the Green Mountain Care Board annual report. So that we'll, we've put that on the schedule. And a shout out to Sarah Kinsler, not to embarrass you, Sarah, and to Christina McLaughlin, who did a ton of work with the rest of the staff putting that together. It's a great document and on our website, if folks are interested in looking at that. The second thing I wanted to update members of the public on and the board knows about this because they're at the meeting is on Monday. I always lose track of days here. Monday afternoon, we had the Green Mountain Care Board general advisory committee meeting. It was a really informative meeting. We heard from our members on what they're dealing with in terms of COVID. We heard some really interesting perspectives from them on the issues they're still dealing with, obviously. We also heard some advice they had to share with the folks like Member Langein, who's running the prescription technical advisory group. So that was helpful. And then the last item that we covered with them was we along with the Director of Healthcare Reform at AHS in Abacus had a presentation that asked for public engagement to inform the potential next agreement with the federal government. So we asked for a written comment from an end written advice from our general advisory for our process at the board to get some public engagement. There obviously are two other signatories on the agreement, the governor as well as the secretary of AHS. All of the input we hear from our general advisory, we will certainly share with the other signatories. But we are also going to, we have two other next steps. We are posting that those slides on our website and on our public comment website. So feel free to check that out and please provide any input. We also next week have invited the Director of Healthcare Reform from AHS to talk with our primary care advisory committee meeting. So that's gonna happen next Wednesday evening. So we expect to hear more as we move along. And I'm sure feedback can be given directly to the signatories of the other signatories on the model. So any questions or comments from the board? The board members on that update or additions? Great, excellent. Thank you. The last thing I just wanted to mention is I am going to be scooting off at about two o'clock today from this meeting. We are giving a presentation in house healthcare this afternoon on some of the work that we are doing, our data team is doing. Sarah Lindberg will be doing most of the presentation on adding race and ethnicity data to requesting insurers to provide that data on claims that will eventually inform a lot of decisions that we make. It also will be an improved the health equity role that we can play. It also will help tremendously with COVID and the vaccine and really studying the impact on our community. So that is all I have for today. Thank you, Chair Mullen. Thank you, Susan. The next item on the agenda are the minutes of Wednesday, February 3rd, is there a motion? So moved. Second. It's been moved and seconded to approve the minutes of Wednesday, February 3rd without any additions, deletions, or corrections. Is there any discussion? Hearing none, all those in favor of the motion signify by saying aye. Aye. Aye. Aye. Aye. Aye. By saying nay, motion carries unanimously with the delayed Sikh member homes. With that the next item on the agenda is the discussion of the qualified health plans, the standard plan design. Dana and addy, did you have any updates or anything that you wanted to say before we began our discussion? In terms of good afternoon everyone in terms of presentation I did want to review with the board the on exchange enrollment data other than that I didn't have a formal presentation plan for today it was really returning to response of questions comments etc. Okay well why don't you go ahead and proceed with that then Dana. Thank you as mentioned we are returning as a follow-up to last week's presentation of the proposed standard QHP plan design changes. I'm joined by Addie Stremelow from Diva our Deputy Commissioner and our partners from Wakely Consulting Brittany Phillips and Julie Pepper will be on hand if there are questions that they will respond to as well so thank you for having us I will share my screen if that's okay and just get into the there with me so first of all I want to clarify that this report is the on exchange enrollment only the reporting for the full market relies on getting enrollment data from our issuers which we are still waiting for there's value in reviewing this on exchange report separately but we will commit to forwarding that enrollment between 20 and 21 or the rest of the market as soon as we can which shouldn't be long we expect to have that shortly so looking at this again this is a snapshot by enrollment numbers the actual numbers of plans from 2020 to 2021 I want to point out that it's combined data for Blue Cross and MVP together so it's to show that you know in this column and this column the change by number by plan also the plan type is combined if there are more than one for example standard bronze plans those figures are combined to give you a snapshot by plan type metal level and each CSR level I want to spend the most time on the color chart the next slide shows those same changes by in terms of a percentage year over year I want to turn to this which is reflecting the change from one to the other first in terms of a percent and then the actual number I also want to point out that in this row it's all NA and this reflective row just to remind everyone that reflective silver plans are only available off exchange directly through the issuers so they won't be included here so as I think had he mentioned last week we have seen fairly significant overall decrease in on exchange QHP enrollment since last year of 1900 that's across all metal levels and we attribute that to we think we're seeing the effects of COVID and corresponding unemployment change in the state and there is an uptick in Medicaid enrollment likely due to you know again the unemployment and and income change for these impacted households looking at some of the things the kind of significant things in terms of by metal level the biggest decreases in the silver area and I think we've seen us before where this is we think largely due to an impact the impact of silver loading which means that it raises the the options where it makes enrollment work selection more complicated in the way for for customers because with the increase in subsidy they there is the option of a zero or very low cost bronze plan which I'll speak to in a minute and for some of the CSR levels 77 and 73 in fact could purchase a gold plan at a higher AV level or a small incremental premium difference and you know depending on someone's expected utilization those choices will often be better than staying in a silver plan how did you get that message out to the public so that people are making informed decisions Dana well multiple ways it's certainly a message that's focused on with our sisters out of training there you know for the one on one assistance through that group it's definitely you know we're not steering of an enroll applicant towards any one plan but it's a factor that would be illustrated plainly in the plan comparison tool because that's where somebody would answer several questions that would you know with their anticipated utilization if something else might be a good option for them to consider other than a silver plan and obviously if if someone is not subsidy eligible and is interested in staying in a silver plan they are strongly encouraged to go to a issuer direct reflective silver plan that will go across so kind of through multiple channels it's it's communicate just want to make sure so I think those are the things that I would really want to draw to your attention with this report for the on exchange and are there any questions happy to take them addy is there anything that you would like to add no thanks Dana good summary okay board members do you have any questions for Dana or Addy hearing none does a board member wish to make a motion before I go to public comment I move that we approve the change in the deductible for the bronze plan without prescription drug limit and approve the change in pediatric vision benefits to align cost sharing across all standards and metal levels and is there a second second okay at this time I'll open it up to the public for discussion before we vote does any member of the public wish to add any input before the vote seeing none is there any further discussion by the board yes Kevin I'd like to spend a couple of minutes here this I recognize that this is a very narrow vote on a very small corner of one plan but you know I had some trouble getting and I'm not even not sure sure I'm there yet getting to yes on this I look at the percentage increases in these plans and for the medical deductible silver plan it's six point three percent for the gold plan it's nine point one percent and the platinum plan it's fourteen two point three percent and this is on top of five-year annual transfer silver golden and platinum plans respectively at nine point six five percent seven point one percent and nine point nine percent and so I think about that and the people that are on the other end of that and I think about the overall Medicaid cost shift I think about the message that went along with the twenty twenty one budget adjustment of level funding Medicaid payments but for federal mandates I noticed that the the reduction in the QHP premium and CSR subsidies from seven point nine million in twenty in 2018 down to six point seven million in proposed twenty twenty two I see little progress on the benchmark plan and even though five other states have moved forward on this you know that is a way to align and lower costs through prevention and I see little progress on the premium cliff we did get a study from Wakeley that said we could lower the premiums by ten percent for those between four hundred percent and five hundred percent for a little over two million bucks and I kind of put that two million dollars in perspective by seeing you know in the overall appropriations for the agency that you know nineteen point six million dollars was found in reductions ten point seven of that was repurposed but there was eight point nine million that you know that fell to the bottom line and I also kind of went back and read the executive summary and recommendations having to do with the implementation improvement plan for the remodel pair of model that was presented to us last November and there you know there's one quote from the findings is that healthcare reform activities that the agency of human services are not clearly organized for success in the agreements and another one recommendation that says organizing health care reform activities in the agency of human services to uniformly drive towards the performance domains in the state federal and state federal agreement so these percentage increases are big if they were all down around the bronze plan at the three to four percent range I wouldn't have any problem as I you know haven't with insurance rates going up you know in the three point five percent range and hospital budgets going up at less of that but I just feel that this is incremental creep and I'll you know you know my preference is to vote no on this and and just because I I don't see this and think about the people that are facing these percentage increases in their medical deductible and and really kind of want to put a stake in the ground and say we we've got to change this I mean we've got to do something about the premium cliff we've got to do something about the benchmark plan and and make progress more progress toward the good here I fully understand the hard work that goes into this but I think it's too narrow of you and so those are my comments thank you Tom other board members so what's your alternative Tom well I don't think that you would want to keep the bronze deductible plan the same and the vision the pediatric vision benefits the same those I don't want I mean I didn't when I was reading you're looking looking over my presentation here I don't include the bronze deductible because you know it's it's down at the four point three percent range in terms of the medical deductible and a three point six percent you know five-year trend rate and I can live with that but it's it's it's getting higher than that you know obviously I've been in a situation as you have Robin where you where you know how to make things happen inside state government I'm outside state government now but I can tell you that you know if Howard Dean ever came to me and said Tom can you find two million dollars to for some premium subsidies or for help those above four hundred percent to five hundred percent I could do it and I think that the innovation plan the the implementation improvement plan says the same thing is that you know all the courses aren't put whereas Mike Mike said in his presentation everybody in the boat isn't rowing in the same direction so you know what I can do is to raise this issue persistently if someone wants me to come over and find the money I'd be glad to try to do that and but that's not my job anymore I just know it can be done if if if the will is there these aren't big numbers two million bucks it's not a big number to help those between four hundred and five hundred percent of poverty it's not a big number other board members so I don't believe I've heard any amendment Robin to your original motion so I believe that we're still on that motion before us before I call the vote is there any further discussion in not knowing what the outcome will be and knowing the rules for remote voting Mike Barber if you could call the roll member Holmes yes member Pellum no we use for yes member Lunge yes Mr. Chair yes so let the record show is a four one vote thank you Dana thank you Addie very good thank you you know we have to remember that the exchange is where people get help with these payments and without a good solid exchange a lot of Vermonters would be in a very dark place so thank you for everything that you're doing so we're ahead of schedule on the agenda I'm not sure if vital has joined us if not I would skip to the third item on the agenda is vital on we are going to try to get them on Sarah Kinsler was going to reach out to them yeah Sarah we are we are on oh I see most of our team are you okay with going going early we are happy to super well we're glad that you're happy to so Beth you can go ahead and take it away great can we we have a member of our team who's going to show slides I'm sure they'll appear as I'm talking but I'll just get started if that's okay that's fine great so we you know we're here for a quarterly update I thought we'd start just with some quick introductions of who we have here or who is joining I will I will ask everyone to introduce themselves but I'll call names so where we know those awkward pauses so I'm Beth Anderson I'm president CEO of idle I'll just go in order of how people are presenting so we have Carolyn Stone people are still dialing in maybe what I'll do is I will give you their names and then they can introduce themselves when they start to talk so while Carolyn Stone our operations director will give you an update on our Club of Services project and our COVID work Maureen Gilbert who just popped on our client engagement director so I'm Maureen I was doing introductions for us Bob turn out who I see Bob do you want to introduce yourself good afternoon Bob turn out here we have Christopher shank there's our director of IT and we also have not not talking but may answer some question Frank Harris our strategic technology advisor so just great so we'll get started Frank are you able to display the slides or do you want me to do yeah I should be outside great everyone see that okay yes thank you great if you would jump to slide 5 what I wanted to do was just get us started was just to give a quick update on what we accomplished in CY 20 when you've heard a lot of it before from us so we'll just give a very high level who's going to do a quick overview of what is in our our new or CY 21 contract with diva which will just set some foundation for you as we go through the rest of the presentation and talk about the club of services project and certainly the the update to the FY 21 budget that you'll see in a few moments so you see 20 our work we started with the plan to spend a lot of time focused on the collaborative services project and the consent right so we successfully implemented phase one of the collaborative services so that included moving the the Rhapsody putting in a new master patient index which you've heard us talk about the improvements to patient matching that resulted from that and a new terminology service to help us do better translation of data we did the kickoff and began implementation of phase two which you'll hear more about in the bet and that was the really the big piece last last year was selecting the new platform to replace our infrastructure and began implementation of that we managed transition to an opt-out consent model in March it sounds like it was much longer than a year ago but we successfully translate transferred to the new model and did I think a pretty robust patient education program which will continue what was not on our list at the beginning of the year was obviously the work we've done with VDH and in support of providers around COVID and so this just to give you a sense you've heard about a lot of the work from us but just to give you some numbers to the work in addition to providing the daily hospitalization report for VDH which saves them a lot of manual data collection from the hospitals we signed up or built interfaces to 12 new locations to get COVID testing results included the state lab as well as some of the testing sites 53 new locations for immunizations and that number will continue currently it will continue to grow we have a lot in the pipeline as the immunization program rolls out and we onboarded 19 EMS agencies to use vital access so they have critical patient data as they're going to respond to emergencies and transport patients we worked with UVM through the cyber attack Maureen it worked very closely with stakeholders to begin discussions around what sharing of sensitive and mental health treatment data might look like if we were to collect it into the VHI we did some work with OCV to expand their patient populations and improve their reporting and we made many security upgrades to our platform thank you for the next slide please turning to the new contract which we signed with diva at the end of December the value of the contract is just over nine million dollars that includes our maintenance and security you know the kind of keeping the lights on work for the VHI as well as then development projects of about five point six million it also includes a task order of four hundred thousand dollars which is undefined work but leaves us some room to identify new work during the year as we found last year in our work with public health new things came up that we hadn't anticipated in the year and will allow us some room to expand that project work next slide please the development work breaks down into a couple of buckets a big piece of it is around the new data platform completing the implementation of the new the new medica south platform we'll be delivering the blueprint extracts to them it's transitioning of interfaces onto the new platform making sure we are aligned to and can meet the new information blocking rules and the interoperability rules that are going into place making sure content happens effectively and then also looking at ingesting new data types and what that will look like for 21 is our goal will be to ingest Medicaid claims data so we'll be working with the Medicaid team to actually begin collecting their claims and helping figure out how to get them more value from combining the data together also be developing requirements for sensitive data and social determinants of health with the intent of really this year being about stakeholder engagement understanding what people would want how the data could be used with the goal of then collecting that data in a future year another 2.6 almost 2.7 million dollars will be around data access and public health so continuing our work with bdh again delivering the daily reporting onboarding new entities for immunizations we're working with them on a lot of data kind of requests and provision of data for them as they help to think about and plan the immunization rollout and we'll continue we'll continue that work we will continue working with providers to expand data collection and access so getting data in new data in making sure everyone who wants access to our data has access to the data we will launch a new provider portal which we believe will be really great will provide some much more usability for providers who have the provider portal and get more data to them at the point of care will continue the meaningful use and security risk assessment consulting that will be expanded a bit this year to also do some consulting around the interoperability rules to make sure providers are aware of how the rules impact them on that they're ready to meet them continue some work on emergency response our data quality work is going to shift so whereas traditionally that's been around work with the blueprint team and their providers we're going to now partner with by state to look at the their data quality models and work that they do with the fqhc's and look at ways of expanding their models to more providers across the state you know in talking with them and work with steva we feel like they have a really robust model that could benefit others and we want to look into doing that also continue work started last year around data governance next slide please we'll also have projects this year happening that you'll you'll see in the budget that are not necessarily supported directly by the the contract but we're underway in strategic planning we're looking at building our sustainability model and thinking about how we how our work is supported going forward um we will be doing more robust kind of stakeholder engagement and storytelling um so really and this is kind of what we brought moraine on um you you've heard me say before is really to do a better job of talking about what the vi does and how we can help um and also kind of reaching out to our stakeholders and the providers across the state and understanding what would be valuable to them and how can we meet their needs we want to make sure that as we that we're truly adding value and truly helping them solve their challenges and not just giving them tools that we think are useful we'll continue our work with one care we did sign a new contract for 2021 with them and we will continue our work to meet the interoperability rules and also working with hospitals to make sure that they are meeting the new requirements particularly around the new conditions of participation requirements so with that um if there are any questions i'm happy to answer them otherwise i will turn it over to carolin to give you an update on operations are there any questions for beth um yes moraine i just had one on you know did you have any learnings from what's going on with with covid and with the cyber attack and and a either how prepared you guys were to be able to help with that or maybe some gaps that you learned from that yeah um i'll give some quick answers i think the cyber attack's an easy one to answer um we need to and we are we're actively working to better communicate with providers to make sure that we are all um prepared right i think one lesson we learned is we didn't have all of the providers set up with user accounts to vital access to the provider portal so we you know it was a big scramble to get new account set up so people could access the data something we might be able to think about doing ahead of time so should somebody face an issue they're ready to go um so i think there are things like that we can absolutely look at and and work towards um and we are uvm has been a great partner and they're helping us kind of think through how we on both ends can learn from that and kind of expand that knowledge to others um i would say from covid you know it's hard to say like i think we're probably excited about our new data platform and the way that that will help us to meet needs like this more efficiently um so so the collaborative services project will show its value i you know i think from lessons and somebody else on the team may have something else to add but i think we were we were able to pretty quickly partner um with vdh and they've been good partners and working with us to figure out what they need um and try to kind of address those needs you know we i think one piece that we we are finding now that we are we're working through um is their ability to share data back with us is pretty unlimited right now and i think so that's a challenge so for us to be able to provide provide for providers um a holistic view of their patience is a challenge and an example and one that we're working through is immunization registry the statute right now doesn't allow them to share that data with the hie um it's there there's um current language in the bill the senate is drafting to change that but that's a problem because we will only have the immunizations that are submitted to us that we provide to vdh but they can't give us back if any have come directly to them not through the v high so you know that's an example of something we we definitely did identify a gap but we are working to address so we can have more robust complete data good thank you any other questions for beth thank you beth uh i i think you said carol was next yep hi um carol and stone from vital and i'm going to give you some updates on both our collaborative services and some of the work we've been doing ongoing work we've been doing to support coven throughout the state next slide please all right so collaborative services uh wanted to get you an update on on this project as it is such a critical project for us um and this is the second phase um we did publish an updated project schedule in december which kind of adjusted for the delays we had um encountered with the project um due to you know numerous other things including coven pulling pulling some uh research resources away um but this is going to allow us to meet our deliverables on time so right now we're looking at delivering the first uh blueprint clinical data extract to them in mid april uh or potential earlier if it gets done um the first medicaid claims file ingested this will only be medicaid coming from um the diva program and um we're going to adjust that into production in july we're targeting our provider portal to be live in july as well and uh we're working with one care vermont on their reporting for later in 2021 um you know to help accelerate we did bring in some contractors with expertise in the new standard uh fast health care interoperability resources that our database is built on um to help accelerate that work next slide um right now we're finishing testing up the clinical data repository and resolving issues we're going to complete the terminology code mapping for the blueprint extract and continue validating and testing that our reporting database and the new data model uh are performing as we expect and um we're going to complete the integration of terminology services which is one of those phase one uh items that we already implemented it's a it's a separate module and we're just going to integrate it into this new platform um on covid um we've been doing a lot of work we're doing our daily hospitalization report to vdh um and then this also ends up supporting the reporting for vermont to the us health and human services agency um we continue to do ad hoc reporting uh as needed to support their planning efforts um and the provider portal is continues to be used by the epidemiology team um to support their case investigations and we are onboarding emergency medical services teams across vermont to help them with uh getting the data on patients they're treating and transporting for covid and um some of the other aspects that we're doing was we're continuing to build interfaces uh for commercial testing laboratories and pharmacies um to the immunization registry uh we've got a lot of new interfaces coming on online uh was both live and in progress um we've built a couple of new types of interfaces to convert text file data to the standardized hl7 format that the department of health expects um to support sources that can't produce these standard formatted messages um so that was a new piece of work that we're proud of um and that's my update on those two areas does anyone have any questions for me questions for carolin from the board i just haven't done the collaborative services and i know that's where potentially there was annual savings both for vital in the state and also cost avoidance and just with any of the delays how is this being impacted or when do you see those coming into play carolin do you want um i think bob best can speak to those questions yeah i i can answer about some yeah i'll start and bob can help me uh you know when it came to some of the savings i think the most significant pieces of the savings won't be impacted and that was largely with the the the work around the blueprint extract which we are still delivering on time for them to be able to get this year so fortunately that was not largely impacted there may be some smaller amounts that were on some software contracts that we had that may extend um a little bit longer but you know when we talked about that that bigger number and i gosh it was over one million dollars i remember the exact number but you know the biggest piece of that was really in the early phases was the blueprint on that that should that should not be a problem okay thanks bob would you know i i i would agree with that um certainly any of the delay and i'll speak to that in another chart um is just going to move things to the right a little bit i mean we're still going to pay subscription fees for uh once we go live and instead of being in december it's now in april so there's a slight difference um and that's represented in the forecast okay thank you any other questions for carolyn yeah i have one quick one um i think it's on slide i think it's on slide 12 now um but uh you say that you're onboarding ems teams across vermont um and use is it on slide 12 uh anyhow it's so you know it's the slide that references um there it is right here vitals continues to onboard ems teams um so uh but if you can put some metrics to that how many teams have you onboarded and how many are there two on onboard um we have i don't know the exact numbers off the top of my head uh but i can look as of the end of lat as of the end of december we had onboarded 19 of them there are moraine you can check me on this there are over 200 um as you can imagine very varying sizes and focus across the state that's right thank you we're partnering with um emergency services at the state to learn more about how they want to um help support this thank you any other questions from the board hearing none we'll proceed all right so client engagement update that's me moraine gilbert um from vital and i'm actually gonna have you jump right to the next slide please frank because this is our our annual report which we submitted just a few weeks ago it's a report that we are required to submit each year to the to you to the green mountain care board also to the legislature and to secretaries and commissioners and deputy commissioners at the state reporting on our activities for for the year and um there's a link here it's a live link in in the document that we sent you and would really encourage you to take a look um it summarizes a lot of what beth was was offering um early in this meeting so um a little bit about what we did this year a lot about what we did this year and then a little bit about what's coming up in 2021 next slide please frank i'm also going to be really brief on the consent update just letting you know that our opt-out rate remains steady and we've got um a chart about that later in the presentation and that we are planning more provider and patient education to begin in in march so next month we'll be putting some renewed focus on provider and patient education next slide please frank thank you so i'm going to provide a little bit more detail here today on our sensitive data sharing project and this is the project to explore the consent model for sharing substance use disorder treatment data and other sensitive data including mental health treatment data through the vermont health information exchange so this is happening in two phases one is designing policies and procedures and this is really well underway um we have engaged an advisory group multi um stakeholder multi organization advisory group and we are doing focus groups and interviews that include representation from independent practices hospitals federally qualified health centers designated agencies and provider associations we're also recruiting for additional stakeholder engagement right now and thinking about um how to include patients in in this work and make sure that that their voice is as a part of this towards the end of 2020 we um did a lot of work documenting the business requirements the solution design and the policies and procedures that we envision here and we're currently waiting with bated breath for implementation guidance around how the CARES Act is going to change 42 CFR part two the um what we're what we're expecting here is that this change could allow part two data to flow just as if it's HIPAA data with no additional restrictions which would be a real game changer and the accessibility of this data um but but there are a lot of details still to be worked out we're anticipating those to come from the federal government in March phase two is the pilot and this is really an implementation pilot we're not not so much a pilot we're not testing the policy so much as how we implement the policy how we educate about the policy the consent model that we will select with stakeholders this year and so the pilot planning is happening in late 2021 um working with a designated agency a federally qualified health center and a specialty treatment center looking to actually turn that pilot on and start the data flowing more in 2022 when we would be iterating with feedback from provider staff and patients on the education approaches and the workflows within those settings so again want to just say that that pilot planning is late 2021 but we're looking at actually turning the data on um in 2022 of course some of this dependent on the the work we plan out with the state for 2022 and that's all from me any questions yeah Maureen this is Robin I had a question um about what kinds of qualitative uh information you're you're learning through your preliminary focus groups and engagement with on the provider sector and that's one question the other is um when would you expect to start engaging with the patient patients and hearing patient issues or concerns or feedback sure um so I will jump in very carefully to the first question because it has not been extensive engagement so far but I think we're hearing some things that that we we can tell you um about that I expect to hold true we'll certainly test them one is that the consent model that we select has to be absolutely reliable so if we're gonna say um this kind of data will will be available or this won't or you can make a choice about x or y we have to absolutely be able to deliver that um and and so that sort of reliability and um kind of precision is really important um the other thing is really about burden on the organizations and what organizations are going to be willing to to take on in terms of additional consent management and and some real concerns about the prospect of taking on um additional work there although certainly especially in um mental health treatment organizations there is a long history of talking um closely with patients about um consent and information flow so just some concern but um also some some interest in engaging there um so the second question about when to engage patients we are both like really committed to this but also entering it um carefully and I'm thinking that will be um early summer of this year thank you um any other questions for Maureen okay thank you um then I'll go ahead this is pop turno from vital um good afternoon um I will be going over vital's updated forecast of the fy 21 budget uh this is the budget that was approved last uh July by the green mountain care board the update um the updated forecast includes um inputs based on actual revenue expenses to date along with um our estimate of deliverables for the new um cy 21 contract that beth talked about and also our projections of in-flight um work next slide please there are four major assumptions associated with this forecast the first is the completion of the new data platform according to our project plan by April 2021 the next is that um the development projects inherent within the cy 21 contract are to be completed by september 30th uh 2021 in accordance with the expiration of the high tech deck um also there's the addition of consulting and contract labor to support vital staff to perform the additional scope of development projects and the public health work in the new contract and finally um we've decreased the revenue contingency embedded in our revenue forecast to reflect what we've learned while we are more confident in our future we recognize that we are still in the grips of the pandemic and this could adversely affect our forecast next slide please in our forecast we see three major risks the need for consulting um and contracting labor with specialized skills in um areas such as fire which carolyn talked about could it see the marketplace capacity which could impact our ability to complete our deliverables two we are also continuing to learn lessons in the implementation of the new data platform which could impact the work scope of this project and finally as i mentioned uh we still see the pandemic as a potential risk with unknown impacts to our financials next slide please with this chart i'd like to add some context with regards to the state funding vital has received in our new cy 21 contract there are four calendar years that are shown um but please note that cy 18 represents an an estimate since our first calendar contract was received in cy 19 the blue blocks represent development projects and the green blocks represent um operation funding generally the growth has occurred in our development projects in which the state has invested in vital to implement and deploy projects such as the collaborative services projects along with the new data platform as beth has mentioned the new contract continues the development in these areas such as ingesting new data types data access access and public health also you'll notice that the increase between the estimate that we used in the f y 21 budget and now in the f y 21 mid-year budget is roughly 1.9 million that is um you can probably barely make it out is the 1,865,000 increase as beth also mentioned the blocks of by state and and also the task orders really represent um funds which we don't anticipate um passing through vital right now certainly the by state work is a a pass through subcontract and as beth mentioned the task orders are for yet undefined work so in terms of the f y 21 contract um the task orders have not been incorporated into that estimate but a portion of the by state work has next slide please this slide is a more comprehensive comparison between the c y 21 and c y 20 contracts i won't spend um very much time on it if there are any questions uh please feel free to to ask them if not we can move on to the next slide this chart summarizes the changes between the f y 21 and f y 21 forecast of 1.7 million dollars for revenue the three major drivers here are the new contract as i just previously mentioned is larger and that adds almost a half a million dollars of revenue to f y 21 secondly the state was able to repurpose funds to cover our covid related work this added 826 thousand dollars although it didn't cover the entire amount that we had estimated for the year so that's why you see a negative 56 thousand above it third we've revised our estimate of the impact of the pandemic on our revenue um we have decreased the contingency from six percent of total revenue to one percent and this adds about 400 thousand dollars of revenue back into the estimate next slide please this chart is an update to the one that was included in the f y 21 budget review and it's been updated for the changes of the new contract and our new estimate for c y 20 work the intent of this chart was to display revenue by contract and whether those contracts had been awarded i see that awarded contracts indicate a more solid estimating base by removing the risk of how much that contract will be funded for and as you can see the only item really left is the revenue contingency line next slide please the f y 21 mid year forecast projects that its expenses will increase by 1.6 million the major points are the addition of consulting and contract labor and temp labor to augment staff and help support deliverables and in addition backfill staff that have been focused on our covid work we have we have added several temporary positions in the forecast and you can see this on the line called labor cost temporary and that adds 177 thousand in addition we have added 1.2 million dollars of contracting and consulting labor and i will show that in a separate chart below we have also added additional spending on data security to reflect our continued assessment and enhancement of our system security our projection for software costs have decreased due to the timing of the go live of the basic system originally this was estimated to be in december now it's projected in april and we don't pay the vendor until the system goes live we have also added additional spending on more comprehensive training for skills necessary for the new data platforms such as fire skills next slide please this chart is an update of what was presented in the f y 21 budget review the intent is to provide a perspective on the relative amount of the various components of vitals expense projection next slide this slide is a update to our org chart that we presented in the f y 21 budget review it reflects our current organization next slide please thank you as i previously mentioned vitals f y 21 mid-year forecast contains additional positions to support the new contracted work scope in the c y 21 contract specifically the forecast adds 3.4 temporary positions a subcontract program manager a part-time medical coder a full-time application systems analyst and some additional administrative support in addition the core staffing increase is the the extension of the tenure of our beloved strategic technical advisor next slide this chart summarizes the change in the estimate for the contracting labor consulting line item between the original projection and the f y 21 budget with the new mid-year forecast it highlights the major differences between the two estimates principally these are the increase of almost a half a million dollars to support data validation and testing on the new data platform this in some way backbills vital staff that were engaged in covet work efforts the next major portion is the by state um vermont rural health alliance initiative on data quality this is the portion shown is 190 000 and that is part of it um that is applicable to the f y 21 contract i mean to the f y 21 forecast next there is additional forecasted support for the c y 21 work scope these are items such as the provider portal and claims data and vital direct work scope which are part of the c y 21 contract and then the next largest piece is additional support in terms of data mapping and technical writing for the operations team next slide please i will close my discussions of vitals f y 21 mid-year forecast with a chart that summarizes the asset side of the balance sheet we believe that at the end of the year vital will remain with sufficient financial resources with 137 days of cash on hand to continue our work on projects which benefit the health care of firm honors and that concludes my presentation today thank you bob are there questions for bob yeah i have a couple um go ahead easy ones i think um so going to the previous slide slide 29 so the difference between uh those two bolded numbers is the 1.229 million dollars yes yes and um in the narrative you have here there's no mention explicitly of covid in the narrative associated with that same number in the um forecast document that that we haven't seen here but came with your materials uh the issue of backfilling for covid by consultants was mentioned and i'm just wondering uh how what are those proportions uh in in the 1.229 million and as we roll out into 2022 um and assuming the world gets better relative to covid is some of what we're looking at in 2021 uh one time expenditure hmm that's a good question um i would say that um what we're what we saw was that um the work on the implementation of the new data platform um was impacted by the covid um relief efforts i i don't have precise numbers on um you know what that um you know that proportionality is um i don't think it's one to one um certainly because as we got into the implementation um we certainly saw that the breadth and depth of the data testing and validation effort was um more than we had anticipated okay um i just to put a little more specificity if that's okay i think bob is spot on you know the the line items on this this page though that you're looking at that where you see those costs um and bob correct me if i don't get this right but under the data testing and validation that 475 thousand dollars a big portion of that is due to the covid impacts but bob's absolutely right some of that was we decided we needed some more expertise that we didn't have and some of it was backfilling a good portion of it was backfilling the staff and then a piece of the the data mapping work also i think was while i was in that um and probably sprinkled among the others but those are probably the the two bigger buckets where you'll see that impact okay and another question um is there's no slide that i saw associated with it but on your balance sheet you had um of values for unbilled accounts receivables and those were growing from 290 thousand in fiscal year 2020 to um the fiscal 21 budget at 668 thousand and the fiscal 21 forecast at seven seven hundred and seventy nine thousand and i'm just not clear what an unbilled accounts receivable is that is here we have performed the work um and we have gotten the acceptance of that work by the state but we may not have actually physically sent an invoice to the customer and the difference there is is just in timing and timing of um when that acceptance happens and also the magnitude of those deliverables at year end okay thank you for that are there other questions of bob i have one on this chart as well um you know i understand the balance between going from consulting to hiring whether it's temporary or permanent staff and and the availability kind of in in each area could you estimate though what the upcharge is to use consultants do you think i mean because it's a pretty big consulting number and a pretty big increase of a million two uh which typically a consultant is going to cost you more than it would if you hired someone knowing though there's a balance of would you be able to keep them on so just just wondering what you're what you're thinking there and if you're going to hire more people if you would you hire more people if you could i guess um offset the consultants and what the upcharge rate of the consultants is i think what bob do you want me to take some of that yeah some of that at least yeah i from the hiring i mean it's a it's a great point that we we keep discussing a lot of what you're seeing in consulting this year is one time need i mean you saw even with our contract the the portion that's development work with some is what's what's been growing and we don't expect that to continue so you know part of the reason the decision for the consulting is we don't we will not have need for that level of staffing going forward and certainly don't want to set weird or bad expectations also skills that we don't necessarily have on staff we will need to hire and we're absolutely looking at that right now and we're kind of doing an evaluation as we implement the new platform what that need is it's changing some of what our needs would be under the existing platform and we're trying to figure out the the balance of that and what that looks like in in terms of the you know the multiplier or or the the proportion that's a tough one because you know when when you look at someone's salary it doesn't necessarily include you know fringe and you know the application of overhead and so forth yeah i would assume all in so you know comparing a consultant who may be a hundred and twenty dollars you know that's an all in with with their markup on it as well um compared to um you know staff who um you know are are in you know the you know the 90 to 95 thousand dollar range i mean you have you would have to add in you know our fringe and our overhead as well and i think the big thing to consider here is and i think it's a point that beth made it is that um and i was trying to emphasize with the chart on the state funding is the peak here um in that we anticipate that going forward that our funding over time is going to be much more much lower than it is today as as we work to digest these projects and um you know you have the trade off when you bring in someone um of having them you know investing in them over a period of time to to gain the skills and experiences to be able to support what we're doing and and really we need skilled people now and in some cases we have to go out and get them because we have you know a really short window to complete our work i hope that if you'd like i mean we can certainly do a more careful comparison just a quick i think a quick blush is um we have consultants that are certainly on par or close to what we probably are paying all in for staff and that's a a bunch of the consultants we do have some that we do pay more for because particularly where we had those that need for really specialty skills like you know moving to this platform that's fire-based to get someone who really has true fire skills is hard and expensive um and so we're paying more of a premium for them because of the scarcity but we'll be happy to provide more detail if that would be useful yeah that's okay i'm just making you know just something to look at and uh usually consultants would be a bit more than a person even i would always add all the benefits in as well i agree with you there it has to be salary plus benefits but um if you can get consultants at the same rate then that that is a better way to go because you don't have to keep them on the payroll but um but to the extent that that's not the case you know trying to figure out where you can make offsets but you know i understand the specialized need and the short term you know that would go against that so that's okay you don't need to follow up anymore then thank you thank you great are there other questions for bob or others on the financials if not we'll proceed to the next section all right good afternoon thanks bob so since we shared an update over the summer there's been an increase in threats to the healthcare industry as we all know and so we have responded with further advancement of our security program and i'm gonna share some of that with you today keeping one step ahead of these threats requires a multi-layered approach to security since that last update over the summer we've made some some significant improvements to multiple layers in our security program and documentation we completed our annual penetration test and revised our incident response plan medica soft vitals new data platform vendor they received a high trust security certification which is a comprehensive national security standard for the healthcare industry or employee access protections we strengthened our password requirements significantly and improved remote access security and redundancy we enhanced our network and infrastructure security by increasing restrictions for internet traffic to our network by implementing next gen endpoint protection and next gen firewalls as well and and finally we're responding to the changes in the threat landscape through the deployment of anti-fishing and anti-spam technologies and by requiring multi-factor authentication on on all server logins as vitals commitment to security continues as well my regular updates on our progress are there any questions anyone has about our security program questions anyone will proceed thank you and now I'll hand it back to Maureen for our quarterly update hi there I'm just going to provide you with some of the the facts and figures about the work that we've been doing recently as you're accustomed to seeing each time we present this is the percent of Vermont patients who have opted out of the V hi as I mentioned earlier this has remained steady over the year next slide please Frank this is our vital access queries by organization type so you can see how those those searches in our provider portal are distributed across the organizations we serve and the next slide will show you the overall volume over the course of the year so this is vital access queries month to month and I think it tells a pretty clear story right here of what the year looked like and that big big jump in November as we supported the UVM medical centers information needs during the cyber attack and also the the needs of neighboring hospitals who needed to get at the same patient data next slide please this next one is queries of the Vermont health information exchange via e-health exchange so the national network these queries come from the University of Vermont medical center and the Veterans Affairs and Department of Defense via and dod especially really strong users of that functionality especially after launching their joint health information exchange earlier in the year we see them querying daily sort of just part of their routine workflow pulling information about their patients through EL exchange including from the Vermont health information exchange next slide please this is our results delivery where we deliver laboratory results radiology reports and transcribed reports directly into the electronic health records of 568 providers around the state and you'll see that results volume relatively steady across the year of course with a dip during that time in early COVID when when folks were utilizing the health care system a little bit less next slide please and this is how that results delivery is distributed across organizations so you can see here that our federally qualified health centers are relying especially heavily on results delivery directly into their medical records and that we also have quite a number of independent practices utilizing that service next slide please and this is the last slide in this set of charts Carolyn will have another piece of information share with you next but this is our meaningful use and security risk assessment consultation that we provide to practices around the state and you'll just see the hours from one month to the next as well as the number of locations that we've provided this service to any questions about any of these charts before I hand off to Carolyn any questions for Maureen if not Carolyn go ahead thanks so just want to give an end of the year update on the interfaces and our connectivity criteria you know our contracted target was 85 interfaces and you know due to some of the COVID work we actually completed 143 newer replacement interfaces in 2020 so lots of work there to support COVID we also worked to update the connectivity criteria last year to include the mental and behavioral health data components which we brought before you in November for approval with the state HIT plan you know and and our plans are to continue supporting both the organizations and the department of health diva and agency of digital services throughout this year to support their you know their ongoing needs with COVID as well that's been a real key piece I think that we've heard lots and lots of appreciation for being able to provide the data that people need so with that I think we are done unless people have questions for us okay are there questions from the board I just I have just one question on the the access queries I mean going from a a number of 9762 in a month to 87,000 just seems like a huge huge leap driven by the UVM cyber attack and is I'm just wondering from being inside your shoes what was that experience like is it as dramatic as it looks on a chart or is it you know or is it just routine and the computers kind of take care of themselves I think the setting up of the 1500 plus users in a matter of a week or two definitely was felt internally once the users are set up and we've provided the training and gotten them oriented then the beautiful thing about the system is that the users can we can support those volumes of queries without much additional effort so you know it was the work and the scrambling involved working to get everyone set up and that speaks to what Beth was talking about where we're you know we're going to be working with the organizations to see does this fit in as part of their disaster recovery plan in any way and what can we do to kind of front load some of that stuff so that we're not caught flatfooted I mean hopefully it happens to no one else in Vermont but it is an emerging threat unfortunately other questions Sarah Kinsler do you have any questions from staff or any comments I don't I just want to thank vital very much for hopping on the call a little bit earlier than they'd planned and for for their kind of collaboration and cooperation and providing us I think some some extensive materials to help us understand their budget one thing that I do want to note for board members is that staff are planning on working with vital and staff at the agency of human services to memorialize I guess or codify the the vital budget process as we've done it the past few years and set some more formal guidance so that's something that the board can look forward to in the spring thank you Sarah so at this time I'm going to open it up to public comment or questions for vital and I see that Mort Wasserman has his hand raised Mort hi I have a quick question for Carolyn Stone and then a question comment for the larger group the question for you Carolyn is you referred quickly to the need for consultants to help with converting data text data that couldn't be entered or uploaded in hl7 format I didn't really understand that I was just curious what that was so the data that we're converting we're actually not using consultants to do that piece but we are taking both immunization and covid test data what we've found is there's a lot of emr vendors in the case of immunizations pharmacy chains things like or even some of the hospitals that their vendors are struggling to produce the standard health level seven or hl7 message format that's been around for 20 plus years and so we're able to take the text file and say you know take take each field of the text file and put it into the appropriate place in the standardized message format and then be able to send standardized messages formats to the department of health and we found the same with the covid testing labs that have popped up all across the nation to help with testing in the pandemic a lot of them are genetics companies that happen to want to get into the covid testing game and they they don't usually play in this world so they don't have systems that can produce standardized message formats but almost everyone can do a flat file which is really a glorified excel document so thank you so the other question or it's a comment i'm not sure has to do with the consent management issue and that marine gilbert touched upon was mentioned elsewhere a long time ago that out of the good good good intentions consent for just participating in the health information exchange was opt in rather than opt out and that made it relatively useless for a long time that has been corrected the issue of consent regarding mental health and substance abuse disorder stuff is so important those two categories of problems have been stigmatized for so long and we're working on unstigmatizing them the getting consent is a very nuanced process i've dealt with it as a clinician getting consents for treatment getting consent for research which turns out to be way harder than getting sent consent for treatment getting consent for testing at one time we had to get consent to do hiv testing that's almost gone now but it really put us behind the eight ball in terms of actually addressing a critical public health problem and now we're at the consent for sharing information so i'm just hoping you are spending wisely and adequately with consultants about this because you could easily scare the the dickens out of folks with substance use disorder or mental health problems and prevent both clinicians from knowing about these things when they really need to and prevent uh with respect to social determinants of health prevent uh state policy makers from knowing what they need to know about the state's patients so i guess that's a blithering comment rather than a question i'd like any more information you have on what you're doing so thank you so much dr waserman for for those thoughts um we are absolutely thinking along those lines and thinking about how what we put in place um collectively because this is a collaborative project and we really are um working closely with our advisory group to to develop this solution and the stakeholders really thinking about how what we put in place now um is going to look five years ten years down the road and really taking a long term approach to this um so we will absolutely keep those thoughts in mind and i think it's really important that we hear from um physicians and physician leaders like yourself about um their experience with consent um and and with accessing data and that's why we are bringing providers into this process um so i think thank you and absolutely be able to keep those things in mind okay other public comment other public comment i see rick dually's hand yeah thanks so much as rick dually from health first and also thomas chinan health center uh in williston and i wanted to just comment on you know my experience with vital axis has been um granted hasn't been this year but in years past has been quite difficult um you know when the first rollout was rough it was the consent issue was you know as you acknowledge was difficult at best um you know the data wasn't great it just wasn't terribly useful and there was a point where um there was significant talk about trying to really integrate the individual EHRs for each practice um with this data so it wouldn't be a separate sort of standalone app or something you had to go to but uh would rather people providers would be able to pull it up you know right within their chart um then save that extra step which i think would go a huge way towards uh improving implementation is there still a focus on doing that or is this still considered a sort of standalone standalone access i can take that one more in um it's definitely still a focus um we currently have a project in flight right now where we are we are connected to e-health exchange um in the past that's one of the national networks and in the past that has been kind of a you had to make each connection all at one at a time they've switched their model um so that the e-health exchange connection is now going to be a hub so to speak where it will be very easy to add new connections and we're in the process of testing that right now so that will allow us to connect to not only e-health exchange but potentially the common law network and the care quality network and that's a much easier way of integrating into EMRs because most of the major EMR vendors are connected to one of those three national networks the other aspect that will allow easier connections directly that is coming with our new collaborative services platform will be the ability to do fire or fast healthcare interoperability resources uh interfaces in the future those are apis or advanced programming interfaces um they they allow the communication to be much more seamless um so there's there's a lot going on in that front um but i would also urge you if you have not been into vital access our current provider portal in a while to take a look um there's a lot more data in there since the consent policy has switched in march so um great thanks yeah i'll definitely take a look i know definitely from an EHR perspective um you know being able to view data is great being able to import it directly into your own EHR really is is invaluable because that's what you know allows the data to be mined in your local system so anything that allows the importation of that data into you know local EHRs is is um ideal but thank you so much yeah absolutely and that seems to be one of the the most common themes that we hear from providers around the state um you know docs are really frustrated when they have to have three different screens going at the same time and anything that can be done that would coordinate everything together is just makes sense so amen other comments from the public hearing none i wish to uh thank the team at vital as always we learn a great deal from your presentations and on behalf of all vermoners i really want to thank you for the way you stepped up during the pandemic and especially during the uvm cyber security um issues that arose and um vital has really uh done some amazing things this past year and we thank you for that thank you for having us today thanks so we're going to transition to the next item on our agenda and i'm going to turn it over to um mic barber for um a discussion on a rule change thank you mr chair for the record my name is michael barber general counsel for the board and uh it's more of an update um on on a rulemaking project um as you know the aco oversight rule rule five governs aco certification aco budget review uh as well as aco monitoring and reporting and kind of the background is for this project is when we drafted the rule um aco regulation was new to the board uh we had issued standards as part of the multi-payer uh shared savings program that preceded the all-payer model but we had not you know reviewed aco budgets or certified acos and you know after several years of administering these processes uh it it has become clear that some changes need to be made to the rule to update it um a good example is that we were all wildly optimistic about the budget review timeline um and as a result the dates in the rule uh regarding when we'll issue the budget guidance when the aco will submit their budget and when we will issue our our budget order need need to be changed and there there are things like that throughout the rule um that we have identified over the years and we have been working uh for some time on a potential revision to address issues like that um for a couple reasons that work has not resulted in something that was complete enough to move forward um and then during the fy 21 aco budget process uh you know you you guys had a discussion about um variable executive uh compensation at acos and asked me to try and incorporate um something into the rule around that and asked me to report back to you uh towards the end of january on um progress on the on the project so um so since that time i i've been working on this as i can um and the update is that i'm probably i would say two weeks away from having a a final draft that would be ready to share with stakeholders um and so my plan would be if you're okay with it to um to finalize the draft in the next two weeks and then send that to the office of the health care advocate uh the the aco uh asked for feedback from them um make any edits uh that are necessary as a result of that feedback and then present a final draft to you guys probably about a month from now or so uh would be would be the timeline and that is it i'm happy to answer any questions you guys might have but um just wanted to give you an update on where things stood and what the next steps were because you had asked for it okay questions or comments from the board since it's just an update mike i don't really need to go to public comment do i um i don't think so um well i'll throw throw it open to the public just in case somebody has uh anything to say is there any public comment on the update that uh general counsel barber just gave us on the uh progress being made on the rule five change hearing none i think that uh people are going to get a good chunk of their afternoon back this meeting has went much faster than uh anticipated um is there any old business to come before the board is there any new business to come before the board is there a motion to adjourn so move second it's been moved and seconded to adjourn all those in favor signify by saying aye aye those opposed signify by saying nay thank you everyone have a great rest of the day