 Good afternoon, everyone, and welcome to the Green Mountain Care Board meeting. My name is Kevin Mullin, chair of the board, and we will start with the executive director's report, Susan Barrett. Yes, thank you, Mr. Chair. Welcome, everybody. Just a brief announcement regarding scheduling. Next week, we have a board meeting on the calendar that's July 1st. At this point, we do not have any agenda items, and unless we receive a need for an agenda item next week, we will be canceling that board meeting. And I want to wish everyone a happy 4th of July, which is next weekend. So that is all. Oh, I do have one other announcement. The July schedule, speaking of July 1st or July schedule, will be posted in the next couple of days. And just as a reminder, we're switching over to Teams, another platform, and all of the information will be available on that press release and on our website. And that's all I have to report. Thank you, Susan. I'm going to call on you again in just a minute to take the attendance for the public record. But before we do that, is there a motion on the minutes of Wednesday, June 17th? So moved. It's been moved by Member Pelham and seconded by Member Usoper. And is there any further discussion? If not, all those in favor signify it by saying aye. Aye. Aye. Any opposed? Motion carries. I'm going to turn it back to you, Susan, for the attendance. Sure. So I'm going to call out the last four numbers of your name of your... Let me start that again. I'm going to call out the last four numbers of your phone number. Please respond with your name so we know who's on the line from the public. I'm going to start with 9997. Amy, vote at one, Karen. Amy. 5-0-0-1. Julia. Hi, Julia. Hi, Julia. 0476. Lisa, if you're on from Blue Cross, Lucille, the Vermont. I know. 2505. I'm going to call Steven. Welcome. 7-4-3-8. Hey, I'm Davis. I am. 0-0-4-3. 7-4-3-8. Hey, I'm Davis. I am. 0476. Hi, Julia. 0476. Lisa, if you're on from Blue Cross, Lucille, the Vermont. I know. 2505. 0476. 0476. 0476. 0476. 0476. 0476. 0476. 0476. 0476. 0476. 0476. 0476. 0476. 0476. 0476. 0476. 0476. 1-0-4-2. 1-0-4-3. 1-0-4-3. 1-0-4-3. 1-0-4-3. 1-0-4-3. Becky Lewandowski with the R.M. 4-1-1-0. Kim Douglas, 1-Cameraman. 1-0-4-2. Robin, Elvis, and MC. 7-1-1-1. Judy Fox from Rutland. Judy. 1-9-7-0 is our office number. I have a 3-0-0-2-3-0-0-0s. I don't know who that is. 847-3-0-0-0. That's Tyler Gothier at OneCare. Oh, hi. Great. Because I'm calling in for more. It's Vicki. Okay. Great. I'm glad you got back in, Vicki. 3-4-5-2. Rebecca Copan. Rebecca. 2-1-3-0. Did I call this one? This looks like a month failure number. Might be an office number. 2-1-3-0. And then we have Carmen Austin. We have Katie Jickling, Lucy Farrand, Orga Media, Dr. Wasserman, Sarah Teachout, Carol Stone. Oh, I see Tyler again. And Spencer Wefler. Did I miss anyone? I think a couple of people might have added, but I think I got everyone. Walter at 4-5-3-4. Okay. Hi, Walter. And did I hear Pat Jones? Yes, she did. Welcome, Pat. Thank you. Thank you. Susan, this is Kathy Fulton from BTQHC as well. Thank you. Great. Thank you, Kathy. I don't see any additional numbers at this point. I'll turn it back to you, Mr. Chair. Thank you, Susan. At this time, we're going to start talking about One Care Vermont. And I'm going to turn it over to Elena Barabee, Director of Payment Reform, to lead us into this discussion. Hello. Welcome, everybody. I just wanted to say a couple of things before Vicki got started. So just a reminder, this is the ACO's revised 2020 budget. It was previously scheduled in March, but we allowed to postpone this date for the ACO to have the time to respond to COVID-19. I think about renegotiating their contracts and adjusting the budget accordingly. So I think you'll see some kind of significant changes over the budget that you saw. So there are still some moving pieces, particularly around contracts that the ACO is working to finalize. I just wanted to point that out that it's not totally set in stone yet. You know, we're going to be working on a staff analysis. We want to recreate a version, a simpler, speedier version of the fall, not 100 slides. But we still need to do kind of robust analysis and show you how the budget is adjusting versus what you have true. So in a couple of weeks, we'll kind of go through the budget order and show you what they should ever... Which conditions are still not, which conditions may require adjustment, and then kind of go from there. So, you know, this will look at things like the admin ratio, which you may have seen, has decreased relative to where it was before. So that is not concerning to us so far. But we'll look again at the SPP percentages and how those may have changed, given final attribution and some of the other payer contracts, and then kind of, you know, round out the rest of the budget order conditions. So just a preview of what's to come. And we look forward to the conversation. Kevin, I think... Can I just say, I think folks need to mute their line. I'm hearing a little feedback. I'll be back. Okay. And I do see there's an additional number standing in 7902 if you could introduce yourself as well. Oh, okay, that number went away. So, okay, I'll turn it back to you. I still hear the feedback. Might even be on your end, Susan. Okay, you're not hearing it? Oh, I hear it. No, no, no. I'm saying that it might be yours that you've got to mute. And I will say that I'm not sure that the internet in Calis is the greatest, because I notice we have a lot of problems whenever Elena is speaking. It could be a combination of factors, but I am hearing some pretty good feedback. So if everybody who's not speaking could go ahead and mute themselves, except for Vicki and Tom, that would be great. And Vicki, whenever you're ready. We're not hearing you, Vicki. Vicki Loner, are you on this call? Is anybody hearing me? Yes, I hear you. I'm hearing you, Mr. Chair. Okay. Are there any slides that we should be seeing? Somebody just gave me a prompt to hit star six because I had been muted. Okay. Can you hear me? We can now. Okay. All right. I was like, come on, I cannot do another technology failure today. Are you running a slideshow or is someone else? Yes, I will. I'm going to present now. Thank you. Do you see my slideshow? We can. We're getting to worry that we lost you again. No, just everything is moving in very slow motion today. So for the record, Vicki Loner, CEO, one chair, Vermont. I also have on the line with me, Tom Borey, who's our senior director of ACO finance and payment reform. We're going to tag team this a little bit. If at any time we lose reception, please just raise a hand. So I know to try to fix things on our end. So with that, I thought I'd frame the conversation that this pandemic has really provided us with a deep insight into all the flaws in our fee for service system currently and how it really has failed our healthcare system when we needed it to support us the most during this public health pandemic. As we all know, it supports volume. It supports things within your four walls. It really does not incentivize prevention, population health management. And I found it interesting. We added a last minute slide to this that the head of CMS just came out in an issue brief calling to action the need to really accelerate what we are doing in our payment reform system right now, that no more can we rely on the fee for service system and really need to make that transition. I believe that we have the opportunity under the all-payer ACO model to do just that, to really accelerate some of these payment reform initiatives that we have available to us so that we can provide some predictability and future resiliency to our healthcare system. Is everybody still hanging with me? I just lost people. Yes, we're here and we have your picture. What we're seeing is provider led reform. Okay. Awesome. Thank you. So oftentimes I'm asked do we need an ACO? What is an ACO? It seems complicated. What's its value? And I thought this would be a really good opportunity for me to just address that with the board and the public really to just distill the value of an accountable care model and to bring it down a little bit of memory lane of when we made a decision as a state to enter this demonstration program with the Centers for Medicaid and Medicare Innovation was to use the ACO as the primary vehicle for efforts. I think you all also recall that the ACO was really created as Medicare's prime vehicle for bringing forward financial and clinical reform and accountability. And that is the main vehicle by which PMMI and CMS is using really to drive a lot of the innovations. They too believe that the fee for service system is not sustainable for the future. One of the biggest benefits I see to this type of reform versus past efforts that we've made to try to really look around the edges of what we could do to change the way healthcare is delivered is that this is more of an inside out reform where providers are really leading the effort. They're taking accountability both clinically and financially. And I think in Vermont it's pretty exceptional the number of providers that have stepped forward to be part of this coalition to really change the way that healthcare is delivered and paid for. If you look to the quadrant on your left, at least it's on my left, under our financial administration, this is one of the large benefits of an ACO in that it can negotiate fixed costs and budgets across payers for multiple provider groups that are not part of the same organizational tent. And that provides some opportunity and less volatility as to if people not having to go at it at their own organizational level. It also provides some fixed predictable payments for providers and I think Tom will illustrate later on in the presentation how valuable those fixed payment streams were during the months of March through the early part of June as revenues declined as services had to be shut down to be able to provide that steady stream. It also allows the ACO to be able to look at the way things are paid for a little bit differently, putting more of an incentive on value in those quality measures over time versus continuing to incentivize volume. The other aspect is population health and this is really having some common set of metrics and standards that caught across the state of Vermont. It also really encourages investments in prevention and also looking at chronic illness. So it's really looking at both sick care and how do we help people stay well. This all leads, in my opinion, to a better patient and patients are experiencing better outcomes. There's more benefit flexibilities. There's flexibilities in the waivers such as being able to go to a skilled nursing facility versus having to spend some time in a hospital prior to admission. They're receiving kind of standardized evidence-based care and from the provider's perspective, really that reduction in administrative burden by having standard quality measures so you're not having, I guess I'll call it death by 1,000 quality measures, although that still does exist and there's still some work to be done there. The last point on this slide that I'd like to make is this really is about integration in the system working together in a new and better way and being able to share both data, resources, infrastructure, not having to duplicate 14 different, let's hope it was 14 different electronic medical records. We know there's much more than that. Being able to work together and team and breaking down a lot of those silos that exist under current structure. I'm not going to spend a lot of time on this slide because we talked about this last time I presented, but as I think about this, there's a lot of programmatic and policy actions that the ACO has taken as we have geared up for a potential surge and as we look to hopefully be in more recovery mode right now. Those fixed perspective payments have really been something that we want to accelerate, we want to drive further into the revenue streams. Right now it's a small percentage of the overall revenues that hospitals and independent primary care have or are receiving in those fixed payments. Really looking at how we accelerated some cash flow to both primary care, the continuum of care, such as home health and designated agencies, and the hospitals during the pandemic so that they could have a good cash infusion and look to see how we could reconcile that later on. Expanding and rolling out some fixed payments with Blue Cross Blue Shield in Bennington, Southwestern Medical Center area that is still ongoing and operating relatively smoothly right now and so we'd look to see if we could expand that into the future. We did a lot to take down a lot of the administrative requirements of documentation around quality measures and reporting for those who are part of the program because we knew their time was best spent helping during the pandemic at this point in time. Building a lot of tools, I talked about the tools that we have developed internally to be able to help providers identify those individuals who are most vulnerable during the pandemic rather because of chronic conditions, frailty, being elderly, alone, socioeconomic status, and making those care and concern calls out to make sure that conditions don't escalate as they stay home in place. I think where we are right now is still looking at how we renegotiate those payer contracts. It's been a big part of our work and as Alina noted earlier, we are still working on those negotiations and I can talk to you a little bit about the path that we're taking and hope to have some resolution to those shortly. Speaking of contract updates, these are programs as they currently exist in our payer contracts. We had the Medicare program, the Medicaid Blue Cross Blue Shield of Vermont for both the qualified health plans and a large group in self-insured contracts and of course new to us this year is an MVP contract. I'm not going to spend a lot of time on the MVP contract. That contract is in place. It's not undergoing any sort of changes at this time. It is a shared savings contract. So we decided to focus our resources and time on the Medicare, Medicaid and Blue Cross Blue Shield contracts because they do provide both upside and downside risk for the ACO and its participants. The three main goals of this were to reduce overall risk to the providers who are participating. So looking at reducing some of those risk corridors for those programs, making sure that this year was a quality measurement action period only and that providers would not be penalized for any reductions in some of the quality measures that really do have a heavy focus on prevention. We've done a really nice job of transitioning to telemedicine and telehealth and that's taken some time to be able to do that. And we also know that there's still a certain part of the population that is not interacting with the healthcare system because of fear and that delaying care could result in some worse health outcomes for them. So it's really trying to get the message out to them as well. We are probably the closest to signing with Blue Cross Blue Shield of Vermont for their qualified health plans and ASO contracts so that I feel is imminent in terms of Medicare and Medicaid as the folks on this call know. Really, the negotiation on the Medicare contract is between the state signers and CMMI, of course, with discussion and input in terms of what the ACO participants can bear. And the desire overall with Medicaid is to be able to align where possible and if all possible with the Medicare program so that we have a common understanding measures risk across all of our programs. So this year has been a fairly extraordinary year from the first time that we presented this budget to you. I believe it was October, close to my favorite holiday, Halloween, and at that time we had set forth a population health plan and budget. As the year started to materialize, we saw the need because of COVID to reduce hospital dues dramatically and recall that hospital dues are both the operational costs here at OneCare, so for the data, the people, the regulatory oversight, as well as funding for the population health programs that support primary care, the home health designated agencies and other community providers. We also saw a reduction in the amount of revenue coming in that was projected for the delivery system reform. That was cut essentially in half from what we had anticipated so we needed to make some adjustments in terms of our overall population health plan. In doing so, we felt like we needed some guiding principles to move through that process with our board and our stakeholders. Our first principle was to sustain the existing OneCare programs because those were programs that were in our contract. Our providers were depending on that financial cash flow, and these are programs that are more core to our overall mission, vision, and value and felt like we needed to keep those going for this year. Programs such as the Care Coordination or Comprehensive Primary Care Pilot for our independent physicians. We also wanted to continue that support and financial flow moving to our network. We also needed to take a good look at what new initiatives we were looking to stand up and whether or not we had the operational capacity to do so. So really looking at the resource demands that would take standing up some of the programs that we were considering this year. And again, you'll see later on in the slide that we've had some pretty large reductions in overall workforce pay freezes, pay reductions, benefit reductions within OneCare, much like the rest of the health care system. And at the same time, we really felt like it was our duty to make those reductions to support our network of providers. We also wanted to look to prioritize those initiatives that we really felt were clinically beneficial for our populations and our communities. So this is a grid of all of the population health programs that we had proposed in our original budget with Green Mountain Care Board. And it would be helpful to really just look at what were the programs we decided using those principles that we were not going to implement in this fiscal year, which were the programs that had some revisions to them, either to the positive or perhaps to the negative. And then what were some of those programs that remained unchanged from what we originally testified. In terms of not implemented, we were looking at rolling out a pharmacy program to really look at medical management and support of our overall care coordination. Not all of that program was not implemented, and the reason for that was based on the operational expense reduction. So that was one of our DSR investments that we had worked with the state on and when the full dollars were not realized, we had a discussion with the state and made some decisions on which programs to move forward within which ones to not implement. We were also set, same with the DSR, to do some work on zero suicide and mental health, not begin that work. And the 2020 innovation, the hospital dues support innovation, I think it was $750,000 we had projected for 2020 and in order to offset and reduce those dues, we removed that from our budget for the year. In terms of revisions, Rise Vermont was slated to expand in order to provide some relief to hospital dues systems because of the reductions in the revenue coming in from the DSR. We did not roll that out fully. We kept it at the current scale right now. And also many of the individuals working within the Rise Vermont program and out of the community were redeployed during the public health emergency. We have our Dulce program, which is working with the pediatricians in the parent child centers. We had hoped to expand that this year and we were not able to do so. Other revisions that were specific to COVID and not because of operational expense reductions was the Innovation Fund. So many of our programs that were receiving funding for the innovations decided that they needed to hit a pause button during the COVID surge ramp-up period. And so we allowed them to do that without any sort of financial repercussions and be able to start back up once they were in better recovery mode. For the comprehensive payment reform program, there were certain quality collection metrics that were required in reporting metrics that were required as part of that program that we eliminated in order to provide relief to the primary care offices. The value-based incentive fund, which is the fund that rewards quality. As you know, we work with the Green Mountain Care Board to be able to reduce the amount of funding, the additional funding that was being put away for the Medicare-specific program that was on top of the Medicare requirement. We also put in some provisions internally to be able to distribute that funding out prior to quality collections as long as we were successful with the payers and having that funding be tied to reporting and not to quality. In terms of the care coordination model, we did a few things with that that were COVID-related. One, we did not implement the payment changes, which would result in paying only for engagement versus paying for kind of building the infrastructure around that program. So we hit the pause on that again for the first six months. That payment change will start back up again in July. We also provided some additional funding for the care coordination model for the whole network in order to provide some cash flow to them, and that will be reconciled as things start to stabilize. The programs in our budget that remain unchanged are the blueprint and SASH funding, and that's for the Medicare portion of the funding. The longitudinal care pilot, which is working with the DNA sites, we had some funding put aside for the designated agencies to pilot insights having a clinician engaged for care coordination of people hitting the emergency room. And new for this year was we had an additional $100 PM per member per year fee structure for primary care who were able to engage both Medicaid and Blue Cross individuals who previously had not seen a primary care physician or PA. In terms of the reductions in hospital dues for this year, as I said earlier, really our mission remains the same, but we needed to evolve our 2020 strategy in order to provide some financial relief to the hospitals that are bearing a large part of this population health reform effort. So we were able to reduce dues by approximately $6 million for this calendar year. When we looked to see if there were any further reductions in population health, there really weren't any that we could see for this current calendar year that wouldn't hurt our provider system and the cash flows that they were dependent on. And so the reductions and the changes that you've seen in population health management are the only ones that we're planning on implementing for this current calendar year. We'll provide you some additional detail, but we were able to realize about $3.2 million from operational cost savings. The bulk of that, probably 90%, was a result of hiring freezes. We had reductions in all of our leaders' salaries and benefits for the calendar year and for a period of time. There was even a reduction in their salaries and benefits. And because of the changes that Medicare was making with the other next-gen programs that they announced, I think a few weeks ago saying that they would essentially reduce the ACO's overall risk for every month that the public health emergency was in effect, we were confident that that would apply to Vermont, although we had not seen anything official about that. And we had to make a decision on a reinsurance policy for the Medicare program. And so we made the decision with our board not to purchase that reinsurance policy for the year, which is a significant cost to the ACO. And with that, I cannot see my colleague Tom, and I hope he can see the screen. I'm going to turn it over to him. And then I assume Chair Mullen will take questions at the end or did you want me to pause for questions now? We'll take questions at the end and just to prepare the board members, I'm going to call on you in alphabetical order for your questions. All right. This is Tom speaking. Quick audio, so can you hear me well? Yes. Very well. Great. Hi, everyone. So I'm going to add some numbers to everything that you just spoke about and walk you first through really a summarized budget P&L. This is similar to what you have seen in the past, but really just highlighting some of the high points of the major changes that occurred between the initial budget submission last fall, winter, and this revised budget that we prepared for you today. So starting on the top row, the total cost of care targets has been reduced by $157 million. And that feels like a big number, but it's driven by almost exclusively the Blue Cross Blue Shield primary program. That is the large group and self-funded program. Two health plans, large health plans, decided not to participate in Vermont's health care reform efforts in 2020. We hope to have them in 2021, but the total cost of care for those two health plans has been removed from this presentation here because we're not accountable for that cost. So that represented nearly $150 million of the change between the two budget versions. The other programs, some went up, some went down, but it was largely due to ordinary attribution updates and finalization of benchmarks. More detail was supplied in the budget report that we submitted earlier this week. Moving down, we have the DSR funding row. This has been spoken about quite a bit, and Vicki mentioned it earlier that we anticipated $7.8 million of revenue from this line, and that was cut in half to 3.9, so we've built that into the budget accordingly. And then really the important row, I think for this point in time is the hospital dues number able to reduce the dues by $6.2 million. We started with a model having a little over $24 million of dues, and it's now just over $18 million. For context in 2019, total dues were in the $28 million ballpark, so we've been able to reduce by $10 million since 2019, which is very important progress for the sustainability of this model. As we move down into the expense section, let's speak a little bit about the value-based incentive fund. We're able to reduce that program cost by $2.7 million. A couple of moving parts in there, but the most material one is a modification to the Medicare mechanics, essentially, of how the value-based incentive fund dollars are accumulated. And with permission from the Green Mountain Care Board, we were able to waive the requirement to pre-fund 0.5% of the Medicare fixed payment, which helps to significantly alleviate hospital dues. It's important to also note that there still is a quality component to that program. It's now exclusively handled at settlement, so it moves to the end of the year and thus alleviates the financial burden on the hospitals during the year. Next, we have a significant reduction to the specialist innovation fund programs. If you recall the slide earlier in the presentation that had those guiding principles, many of the initiatives within met those general criteria. They were either expansion of programs, existing programs that hadn't yet occurred, or new program initiatives that had costs associated with them or perhaps intensive resource demands of one care in Vermont. So we were able to reduce $3 million of expense in this area, essentially without pulling out the financial rug from participants in the network. And it was really important in any of these program changes that we didn't take existing funding streams that the network was relying upon and abruptly halt those fundings, those dollars. That would have been just very disruptive to an already financially strained healthcare system. Moving down into the infrastructure section, the first row is general operations. This is really the one care Vermont floor here in Colchester. $3.2 million of savings. That is driven largely by human resource modifications. We have implemented a hiring freeze. Leadership has taken compensation reductions like many of our participant hospitals. And we've also updated some operating expenses such as mileage. Naturally, there's just not a lot of travel going on right now. Maybe expenses that would have happened from meetings, catering food, things like that really gone through all the operating expenses and thinned out as much as we possibly could. Next, we have the risk protection. This is the reinsurance type arrangement. This was an interesting conversation. We had a number of discussions at finance committee and the board, but ultimately the decision was made to forego purchasing a policy in 2020. The interesting components of this conversation are that there's a lot of uncertainty, and ordinarily that is a good time to have an reinsurance type policy, but it also makes crafting and arrangement very difficult. When we don't have clarity about the true downside risk exposure that we're going to have come settlement, it is hard to really price a policy or set terms. In addition, it's looking like we're going to have an adjustment to our benchmark. If we don't have any insight into that at this point in time, that also makes it very difficult to place a policy. Because of some of the complexities, also the general sentiment that the total cost of care has been low for a number of months, the decision was made to forego that policy. The savings there help us to offset hospital dues. We can go to the next slide. If you went backwards one, Becky, just go down two. Thank you. Just to put some numbers in play here, the budget process really had to balance the need for this dues reduction for the hospitals with the consistent funding of the provider community. We're always measuring those two different components. In the end, we were able to deliver the dues relief that we mentioned previously, but also sustained $20 million of plan investment in primary care, $60 million of plan investments in community providers. It's the mental health community, home health, et cetera. Along the way, we were able to advance $2.1 million to network providers, really in that heavy stay home, stay safe period where fee-for-service revenues would have been at their lowest. All of those components are really important to ensure that we're doing our part to help take care of the participating providers. And to the extent possible, keep cash flow ongoing. Next, we have the fixed payments. So, really to Vicki's point at the beginning, fee-for-service is very problematic when you have this type of a pandemic and volumes decline so rapidly. We were able to sustain the hospital fixed payments at the pre-COVID levels through June. And this was discussed with the finance committee and our participants around the right strategy, but it was decided that it was the right approach to sustain the funding at this pre-COVID level. And meanwhile, we saw very significant reductions in fee-for-service equivalent. When we did some math on this, $38 million of sustained funding from the fixed payment model. And this really is evidence of really why a fixed payment approach rather than a volume-based approach is much more stable for the provider community. And it honestly feels good to be able to keep this kind of funding flowing to our participants in times where volumes and fee-for-service revenues would have otherwise been plummeting. And with that, I'll turn it back over to Vicki. Thank you, Tom. So I think this all sums up that there were challenges present previously to health care reform efforts and now we have some new ones to the soup, I guess. The system right now is fairly fragile, so we're looking to really laser focus on our efforts on what are the investments that we need to be making as a system of care to really promote health. We want to make sure that any individuals or populations that have stayed home and delayed care have the opportunity to be able to receive that care and do not continue to decline in their overall health, really looking at ways, because hospitals aren't able to invest in the population health efforts alone as they were pre-pandemic. So looking at some ways to share some broader accountability across the state, as well as opportunities for additional revenue sources that might be available to us. In the next year and a half, I think we'll be in a period of rebuilding and the amount of risk exposure that is currently being taken on by the accountable care organizations and its providers is too high. So we really need a, I'll call it a glide path for the next year to get agreement from the payers to be able to reduce that overall financial risk and exposure until that stabilization occurs. I said in previous testimonies that, you know, we probably need to start looking at what are the metrics of success during this pandemic in terms of our overall care evaluation and budgeting for this type of model in the future. And all this is to say that if there wasn't a dire need for reform before, there is now. And we really need to start working together as a system. We need to think of ways to really leverage the all-payer model ACO agreement that we have to move this forward to provide that sustainability and predictability that the healthcare system and for monitors just, they need that sustainability and predictability. I think one of the biggest challenges that we're up against right now is timing and regulatory pressures. The hospitals need to submit a budget coming up in July. We are required to think about what our programs of events will look like for next year, what our overall risk corridors are going to be for the payers, and we're still in the process of renegotiating 2020. So there's a lot of uncertainty right now in a period of great uncertainty, which makes this a challenge for all of us, and I think we need to think creatively and look at opportunities to really provide relief where we can as we move forward. And I think I just said this last slide. We have an amazing opportunity with the all-payer ACO model, and we should really be thinking and looking as a system of care how we can capitalize on that in order to drive the reform efforts forward. There's many levers that are left that we could be looking at, and I think that we should be talking collectively as stakeholders to see are there opportunities that we have missed because transitioning to this value-based system is really an investment in our future and one that we can't forego. And with that, I'll leave you with Sima Verma's quote, really, now more than ever, it's clear that our fee-for-service system is insufficient for the most vulnerable Americans because it limits payment to what goes on inside a doctor's office. The transition to a value-based system has never been so urgent, and I couldn't agree with those statements more. So with that, this is our question-and-answer slide, so I will open it up to the board for questions of Tom and I, and I can see Tom right now, so I think we'll be able to go back and forth and decide who's it. It's always good to finish with a quote from Lou Holtz. So with that, I'm going to start with Member Holmes. Okay, great. Thank you, and thank you also for the materials that you sent. I'm looking forward to digging through them a bit more and continuing the conversation with our staff analysis in a few weeks, but I do have a couple of questions at the moment. So one of the things that strikes me is, scale is really key to healthcare reform, so can you talk a little bit about the Blue Cross Blue Shield primary health plan opt-outs that you mentioned reducing the revenue? So remember for the ASO program that each self-insured and group was able to opt-in or opt-out from the particular program. We did receive opt-outs from two... We not personally, Blue Cross Blue Shield, received opt-out from both the teachers' union and the state inflation. Okay. That makes sense. I wasn't sure if that was who you were referring to. So perfect. Thank you. Expected. Given the financial health of the hospitals, have you made any adjustments to the risk model? And what are the financial criteria that you're using to assess current ability of hospitals to take risks? What metrics are you looking at if you've made any adjustments? We haven't made any adjustments yet, and then I'll let Tom take over because we're still trying to negotiate adjustments with the payers, and those have not been resolved yet. The payers haven't agreed. We did go out and survey all of our CFOs, CEOs. We looked at overall balance sheets. We worked with VOS. We came up with a risk corridor that we felt was achievable for the ACO and its financial participants, but we're still in a bit of a waiting pattern on that. Do you want to add more to that? Yeah, I'll say we were hosting a series of finance retreats early in this calendar year to start discussing potential modifications to the risk model as we mature and evolve as an ACO. Then the virus set, which should honestly solve this work a little bit, as we shifted focus to making sure that our upstream payer contracts had as low risk as we could possibly get them. While there's still work to be done on what the ultimate risk model looks like, I think there's a couple of themes that are important to note. One, there seems to be general agreement. We need to broaden the financial accountability across the network. And then the second one is there still is a lot of interest in the HSA-specific accountability model, and we need to continue evaluating that. And if the hospital is the primary risk bearer, it's still right. So there's work to be done, but I do think that the virus has shifted our focus more to the upstream risk rather than how we delegate it within the network. Okay. And actually, when we think about COVID, obviously there's been, as you mentioned, both mentioned there's been an increased appetite and appreciation for fixed payments. So I'm wondering if there's been interest from providers for expansion or participation in the CPR pilot program? We haven't really queried the network yet. We're getting into that recruitment phase now. And I would think there will be added interest, but I have not specifically heard from anybody yet. I think the model adds an element of stability that now more than ever is evident as a real benefit. Okay. And I guess my last kind of question is around the variations in care analysis that you do, thinking about it in the current climate of COVID and with some reductions in population health investments that are now going forward, population health investments for one way, the ACA is going to view through which it was going to address the cost and quality differences across HSAs. So I'm wondering where you are at with that analysis that you do and policies that you might implement as a result or investments you might implement as a result of differences in cost and quality across HSAs. I think one of the challenges is that the payer data here has not been as reliable or readily available to us. And so that type of analysis has not been completed. Okay. And obviously I know that we're obviously in a different world of care anyway, but I was just curious, given the reduction in population health investments, if you're the analysis or the methodology was going to change in any way, but got it. I think that's it for me. Thank you so much to dig into and think about it. We're going to be talking about this in the next few weeks. And I look forward to the staff analysis and dig into some of the materials you all submitted in the past few days. So thank you. Thank you, Jess. Next is member lunch, Robin. Hi, thank you. Hi, Vicky. Hi, Tom. Thanks for your slides and information. I actually wanted to start with a submission that you made earlier, but I didn't touch on in your slides, which is the 2021 Network Development Strategy document that was submitted in April. I was curious to know how COVID might impact that development strategy and that timeline. So Robin, this is Vicky. As part of this, we've had some discussions with the payers we've been provided with some relief from Medicare in terms of submitting its roster list until the end of September. We're working with the other payers in the same vein. It's very difficult for us to be able to send out a contract for 2021 when we're not clear on what the terms will be yet, what the program of payments will be. And so I think we're going to see that that time frame gets delayed and in terms of provider participation, I think for this year there's a lot of uncertainty right now and a lot of financial pressures that will go into this. So our overall goal is to at least preserve the network that we have in place, but an expansion at this point in time, I would say, is highly unlikely unless there's some significant changes made to the model. Okay, thank you. It sounded, I was interested in a little bit more information on the Blue Cross Blue Shield fixed payment pilot in Bennington in terms of how it's rolling out and just a little more qualitative description of how that's going and whether you would expect that model to grow to other communities next year. Yeah, I can speak to that. So we started this pilot in April, so we only have a couple of months of experience, but everything I've heard from Southwestern Vermont Medical Center is very positive. I believe that they're correctly processing claims, which is an area that we've had problems with other payers just to make sure that that's working appropriately is encouraging. I think the word coming from Southwestern is going to be really important to help convince others that this is working effectively and is a viable option for next year. The other component is we would much prefer to have an unreconciled fixed payment model, and while we test this out, we are reconciling. I think that's appropriate as we ease into the concepts here with Blue Cross, but if we can deliver and work out the right way to do it with Blue Cross, a non-reconciled fixed payment, I think the appetite for this type of rollout will grow. So encouraged by the early results, but there's a few other steps that we need to evaluate and just take a little bit more time before we really aggressively push it out to a broader list of participants. Great. Well, thank you for that update. I knew it had been implemented fairly recently, so it's just good to hear how things are going. Sorry, I'm just going through my notes here to see where my next question was. In terms of... So, Vicki, you touched on this. In terms of the complex care model changes that you were intending to implement, you did indicate that they would start in July. I think your report was shooting for July 1, but how do you... Do you think that that's more realistically going to be later in July, or how is that going? We are planning on rolling that out for July 1. Okay. Great. Dulce, in the report that you provided, you mentioned that many of the pediatric practices, primary care practices, had moved to some telemedicine visits for this program, and I was wondering if you'd have any feedback on how that worked. I do not personally have that feedback, but I can certainly talk to the folks within OneCare that run that program and be able to get back to you with that information. Great. I think... Those are my questions. Let me just check one more page of notes. No, that's it. Thank you. You're welcome. Thank you, Robin. Member Pelham, Tom. Hello, Vicki and Tom. I hope you survived these last six or seven record days of eat. We haven't melted yet. Say it again. We haven't melted yet. I have, I tell you. So my first question has to do just with aligning these attribution numbers a bit. This is the report from John Zipko where there's a sentence that says, in total 2020 represented another year of significant attribution growth, but the table just gives the 2020 profile. So in terms of comparing it to where we've been previously, that date is not there. But then I would kind of point to another document that's in process at the Green Mound Care Board, which is the draft annual scale targets in the end of the report for 2019. And that does include a chart that profiles attribution growth from 2017 through projected 2020. Although that 2020 was based on the budget that you submitted previously, not these updated numbers. So my suggestion is that if I could think that these two reports should align with each other, and it might be that Elena and Michelle and you folks have spent a little time making sure that things are coordinated. I will know in John Zipko's report on page 5. She says, One Care has received an additional 28,515 lives through the expanded attribution from Medicaid in 2020, yet in the chart under Medicaid expanded, it's a 21,178. So I'm just wondering whether I'm missing something or is that a typo or what might explain that difference? Yeah, I can explain that. So we get initial attribution prospectively before the plan year even begins. So sometime in October we'll get, for a Medicaid program at least, an initial attribution run. The same dynamic happens for Medicare as well. A number of lives drop out before the program even begins. So typically when it comes to budget work, we use the actual number of lives that cross into that January 1st threshold, actually into the performance year. How the scale target lives component works may be different. I'm not sure exactly how the Green Bank Care Board treats that particular nuance, but that would be the reasoning behind what really I'm using in the budget to calculate estimated total cost of care, estimated PHM revenue or receipts, things like that, versus the scale attribution which may be different. Okay, thank you for that. I would just again suggest that our folks make sure that all of this is aligned so that we're not looking at different documents that say different things. And it might be definitional, or it might just be two people working, two entities working collaboratively, but in separate space. I'm looking at the discussion again in Jones and Zipco's memo about complex care. And it would seem to me, and certainly that this pandemic was a huge test for the complex care system that wasn't expected, but I heard from a number of people that our complex care system was very helpful. And so I'm just wondering to give some detail to the conversation that the system was very helpful from the pandemic. Do you have any insight into those that are in the risk categories three, which are a full onslaught of a chronic disease and category four complex and catastrophic patients. Do you have any numeric or documented profile of how that system responds during this pandemic? We are in the process of gathering that data. We do keep track monthly the information in terms of how many people are under care management, what kind of level of care management they fall into. But in terms of evaluating just that specific cohort, we don't have the data yet to be able to do the evaluation on that specific cohort. We do have evaluation on individuals who have consistently been in the complex care coordination program I think over the last 18 months where we can show the overall outcomes and results of those populations that have been undergoing care management services. Thank you. My next question has to do with the distribution of hospital dues and the reduction there. And as you noted, it's a little over $6 million, which is 25.5% of what was originally budgeted. But if you look at some of these percentages different by hospitals, there's quite a spread. There's this low for Southern Vermont Medical Center at 20% and as high as from out of Skutney at 47%. And I'm just wondering was there any noise around this reduction process or is it that the logic behind each hospitals reduction is a logic that the hospitals accept and understand? Yeah, that's a great question. When we make the budget changes, it updates the aggregate dues number. So moved from 24.4 down to 18.2. There is a logic that defines the way in which the 18.2 is divvied up and allocated to each of the participating hospitals. That policy goes through Finance Committee and the Board every year for review and update and involves a couple of different components. There's some financial relief for critical access hospitals and also the amount of Ph.M. dollars coming back to the hospital is a factor. So a hospital that employs primary care will be subject to a different type of dues structure than a hospital that has no primary care and that was decided really for some equity purposes back in 2017. And every year we talk about this and evaluate further and at this point in time no significant changes have been made to that dues logic. Thank you for that. Two more quick questions. I took a very quick look a while back at the Diva contract with you folks for 2019 and it was 130 pages long which I thought oh my god wow. But when I got into what I found that pages and pages and pages and pages of it had to do with the elimination of or the waiver of prior approvals for certain procedure codes. And I didn't take a look at the 2020 draft but I guess in exhibit one. Can you talk a little bit about what quantitative benefit you might be aware of in terms of the elimination of prior approval for those hundreds and hundreds and hundreds and hundreds of codes in the Medicaid contract? This is Vicki. I would say from the provider's perspective if you look at UVM alone, I think I heard a statistic the other day that prior authorization has about 44 over 40 FTEs associated with it so anytime you can reduce prior authorization you can redeploy people to direct patient care, to care delivery not having to have that administrative burden of calling and asking for that prior authorization and providing that clinical documentation for the insurance to be able to look at it really again back to the ACO model it really puts the clinical and financial accountability in the hands of the providers. So that would logically I think be savings for both the provider and the payer both ends of that transaction. Yes and we yes and we also to make sure that there aren't any dramatic changes in any of the particular codes that previously require prior authorization, we track that on I believe it's a monthly basis to be able to review any sort of trends that are statistically significant in terms of over or under utilization of certain codes because both are important factors of quality. Thank you for that and my final question has to do with the budget for specialist program innovation, the innovation fund and the VBIF quality initiatives and so it is right for me to understand that those associated numbers of the 2020 Green Mountain Pair for number two those are carrying forwards from a prior year. There is some of that, yes you are correct. So there were a number of specialist fund programs where we committed to funding an initiative that had multiple years. One example was a chronic kidney disease initiative so some of the funding that remains or expats rather that remains is reflective of those prior commitments that were made so again going back to those principles we didn't want to pull the rug out from the existing or committed funding streams to the extent that we could. Okay so what I'm responding to is again in Joan Zipko's memo and I'm quoting here note that the specialist program innovation fund and VBIF quality initiative line items are funded using hospital dollars obligated in a prior year. So basically it is being sustained on carry forward funds. That is true in the other revenue line on the screen you can see up right now one of the other revenue streams is a deferred dues fund and whatever we've generated those dollars to be used for these multi-year innovation or specialty fund programs and then as the expenses are incurred we recognize those deferred funds. Well thank you both for what you do and your efforts over this unusual period of time. I'm sure it's been daunting at times but you're still standing and congratulations for that. Thank you for 102 days in counting or something like that. Thank you Tom. Now we'll turn to member Yusuf or Maureen. Sure. Hi Vicki and Tom and thank you for this presentation. Several of my questions have already been asked but just to touch on a couple of things one, this is a good page to have up. On the general operations where you've seen the $3.3 million in savings from 20 from the original budget and I understand some of that is compensation changes that maybe people have taken but beyond those are there learnings for savings that could carry forward as you go into 2021 as well? Have you gotten any efficiencies or things like that that may be able to move forward into future years? That's a really good question. I think we're probably still in the evaluation phase of that as we start to really flush out the 2021 budget model but probably similar to many other businesses we're evaluating our effectiveness in this remote space and how might we be able to use that to our advantage in the future. That being said one of the savings comes from activities where we'd be sitting face to face with our network and that to me remains pretty important. We need to be communicating and having these complicated discussions with our network participants and some of the savings that we've built into this revised budget. I would advocate that we actually do want to get back out on the road a little bit more and see our participants face to face. It's a really good question. I think it's something that we need to continue to evaluate but I'm not sure we have fully fleshed out how we can take the circumstance and our learnings to date and really recast them into a 2021 budget but I do think it's possible. I definitely think it's something to look for and I think many businesses will be assessing similar things. What did we sacrifice and what could we potentially do we maybe not need as much for. Obviously we're pretty focused on the administrative side so I think it would be good to look at that moving forward. The next question I have is on the re-insurance or the risk protection and you talked a little bit about it but just to dig a little bit deeper on when you made that decision, how early in the year can you make that decision I guess because obviously you think you would need to sign it up relatively early in the year and then the potential risk that you have since you no longer have that risk protection and I think you typically looked at using it for Medicare which was the largest revenue category and the largest area of risk and also then fast-forwarding that to 2021 how do you weigh that and decide whether you would be paying for the risk protection again. Good questions there. Typically we started the conversations with our counterparty very early in the year and then it just got extended and extended as the virus hit and there became more and more unknowns you know you prefer to have something locked in earlier in the years a little bit more fair to both parties because every passing month we get a new data file and that adds information to the picture that could be favourable or unfavourable and it starts to make the negotiation a little bit awkward but you know in terms of like the actual time you have to have something locked in this is a custom arrangement you have your traditional insurance for your house your car those are pretty standard but there's a whole market of these call them exotic insurance protections and you can negotiate whatever you want with them you just have to have a counterparty to accept the deal so there's no set in stone end date it was getting the point where there were more and more questions rather than more and more answers as we got deeper into the year what's our ultimate risk going to be what's the final benchmark going to be we don't know that right now based on this anticipated retrospective regional adjustment so it makes it just very difficult to craft a policy and and then enforce it at the end of the year there's a lot of numbers that changed and you wrote the policy in a certain way so I give this C dispute coming up where we agreed to this and it ended up not being this how do you resolve that so we just last month or this month rather at this month finance committee and board cycle made this decision the board made this decision so it just happened now it was discussed at prior month finance committees as well so it wasn't sprung on them in one or both I've also been in contact with the other party who I would like to work with in the future I found it to be pretty agreeable and we're both committed to you know re-engaging in the conversation next year that was one of my goals to make sure that we didn't throw out the baby with the bath water on this one because I think there's a lot of question marks about next year too and it might be appropriate to have a similar protection in place for 2021 and could you go beyond Medicare if you wanted to we could Medicare has been the big risk number but it might be appropriate to start thinking about whether or not some others come into we want to have a protection for another program as well I just think maybe in order to get all the hospitals able to participate and minimize the risk to a degree you know should there be huge huge issue where we go deep into the risk area we would allow it to be a protection for many of the hospitals but those are the only questions I have, thank you very much you're welcome thank you Maureen at this time I'm going to ask Elena if the staff has any questions we don't have questions at this time we're going to wait for this week and then have our staff analysis in a couple weeks or no okay great so at this point I'll open it up to public comment and if you could hit star six to unmute yourself and go ahead public comment Chair Mellon this is Susan I just wanted to make sure there wasn't anyone else who joined after I read the numbers I did hear Susan and I did see her number so I know she is in addition but I don't know if there was anyone else who joined after I read off the numbers if you could announce yourself that would be great okay Susan Michael Michael Michael yeah I joined a little bit late thank you okay thanks Mike and I heard someone else Erin Flynn from Viva Erin Flynn from Viva great welcome thank you okay I'm going to open it up to public comment yes go ahead hi this is Walter I wanted to look back at one of Tom's comments about the prior authorization and as someone who nearly lost his life because of prior authorization I'm curious why we need them at all we have the power to stop them we don't need them well I'm not sure that we have the power I think the legislature would have the power I don't know Walter if you recall that I had a bill back probably seven years ago now maybe longer that would have done away with prior us and at that time the legislature bought into just a pilot program and I thought the program went well but nobody seems to be buying into it at a meeting last year the board especially member Holmes proposed a gold card program which I thought made a lot of sense because basically what it was saying was anybody that was using the proper describing methods would be given the gold card and wouldn't have to go through the prior authorization process and I thought that made a lot of sense because it not only rewarded the already good behavior of some but it gave incentives for others to build up their practices to the point where they achieved that gold status as well but I don't know if there's been any further discussion in the legislature this year yes thank you chair well and I wanted to add that indeed that gold carding language is in each 965 which is with the senate health and welfare currently and it did pass out of the house and there's also other prior authorization language built upon consensus work that payers and VMS as well as others came together to create and the committee also took into consideration the work that you referenced chair mullen regarding some of the board meetings we had around the administrative burden of prior authorization so that language is on the senate health and welfare website and I'd encourage you Walter to take a look at it it's encouraging it's not there but it's a start what's the bill number h965 I'll send it to you oh sweet thanks you may want to talk about some of the efforts in the model as far as prior are you talking to me I'm sorry Vicki oh I didn't hear yeah I think we've been making great strides with diva in terms of looking at turning off the prior authorization requirements for the ACO participants that are participating in the model moving forward and we have seen really nice results with that in terms of pretty stable utilization of services and no quality concerns from turning those off absolutely support that moving forward with other payers so I'm happy to see that there's some legislative efforts and I just want to correct the record it's h960 h965 it's the CRF bill I keep getting them confused those pesky numbers they are okay other members of the public yeah other members of the public thank you I have I've served on the diva clinical utilization review board for a number of years and there was an experiment with diagnostic radiology and gold cards which as I recall worked out quite well but there are different kinds of prior authorizations and I'm not sure which ones are up for grads some are for diagnostic testing some are for pharmacy and that's another thing so I wonder which ones might be in that bill that Susan Barrett just mentioned are you there Susan sorry I was on mute I was sending it out to I was sending the bill out to Walter I will I can get back to you Dr. Wasserman but I do believe that referencing is exactly what Chair Mullen was referencing was the pilot project that we did several years ago but I'll send you a copy of the bill as well and I'll get back to you on what's in it great because there are very different kinds of prior authorizations and with the what pharmacy benefit managers do in moving around from proprietary to generic meds for various conditions it can be very confusing to a primary care physician who is used to prescribing the generic for a certain group of beneficiaries and then all of a sudden learns that from a patient that they've showed up to pick up their generic and it costs them 70 bucks for the month so I think it's worth discriminating between diagnostic testing and pharmacy benefits that's all Dr. Wasserman just to address that for a second I just wanted to clarify for the record that our prior author exemption is not for pharmacy because we are as an ACO not a financial risk for the pharmacy benefit management that happens at a retail pharmacy we are responsible for any kind of medications that are essentially administered in the hospital or the physician office though Thanks. Other public comment? Hearing none I want to thank Vicki and Tom for an excellent presentation I'm sure that we will be following up with some questions and appreciate your time this afternoon I also appreciate all the efforts that you've done to try to put some liquidity back to the hospitals in the form of reduced dues that has been truly an exceptional time period and one that I'm sure will never forget and hopefully will never have to live through again but thank you for all that you're doing with that is there any old business to come before the board? Hearing none is there any new business to come before the board? Hearing none is there a motion to adjourn? So moved second It's been moved by Maureen and seconded by Tom to adjourn All those in favor signify by saying aye Aye Any opposed? Thank you everyone have a great rest of the day