 under the names. And you want me to just read off the phone numbers to get an attendance of who's at this meeting. That would be great, Chairman. I, I, this is Robin. I think the names and numbers that each of you see may be different depending on who's in your contact. Because in the past, sometimes Kevin, you're reading off names that I can see. I mean, you're reading off numbers and I can see the name. Not a complicated thing, but No, that's a good point. I forgot about that, Robin. Yes, it's whoever you have saved in your contact. So that's why it's been a little different. And I forgot. So thank you. Kevin, you could read Abigail, who I have in my contacts are Amarin, Mike, Susan, Elena, Lynn, Abigail, Michelle, Jessica, Robin, Kate, and then moving to those that I do not have as contacts, I'm going to read off the last four digits of the phone number and the person could tell us who they are. The first one is 9997. Amy brought up the one here. Thank you, Amy. The next one is 8869. Toby Howe, MMR. Thank you. The next one is 4191. Devin Green, Buzz. We should learn that one. The next one is 8869. Toby Howe again, MMR. Okay. The next one is 2505. Jennifer Collis, UVM Medical Center. Thank you, Jennifer. The next one is 6376. Mort Wasserman. Thank you, Mort. The next one is, I think that's you, Abigail, you must be on your phone as well. Yes. Okay, so I think we have, oh wait, no. Much more to come here. 1042. Robin Alvis. Hi, Robin. I believe that's the office. 3212. Hi, Kathy Mahoney from the advisory council. Hi, Kathy. 1, 2, 3, 2. ACVMC. 5, 817. Jill from Vermont Medical Society. Hi, Jill. I see Susan Aronoff has joined us as well. And we have Orca. We have Paul Ravellin and Carol Stone. Did I miss anyone? Julie is a high-health care advocate. So I heard Julia Shaw from the healthcare advocate. Who is the second person? Susan Grotowski, MVP. Hi, Susan. Is there anyone else? Barry, 1 Care Vermont. Thank you, Sarah. Anyone else? At this point, I'm going to turn it over to Susan Barrett for the executive director's report. Susan. Thank you, Mr. Chair. Welcome, everybody, virtually. I wanted to remind folks to please check our website weekly as we are listing our agendas on our website that is on the Green Mountain Care Board website. And if you click on board meetings, the agendas as well as all of the materials for the meeting are located on that portal. I want to remind also the presenters today to please use the page numbers as folks on the line will be following the slides and the materials through the website. And that is all I have to announce, Mr. Chair. You're on mute, Kevin. Thank you. The next item on the agenda are the minutes of Wednesday, April 1st. Is there a motion? That moved. It's been moved and seconded to approve the minutes of Wednesday, April 1st without any additions, deletions or corrections. Is there any discussion? Seeing none, Mike Barber, if you would call the roll. Member Lunge. Yes. Member Pelham. Yes. Member Youssefer. Yes. Member Holmes. Yes. Mr. Chair. Yes. Thank you. At this point, we're going to move on to a discussion of a possible letter to be sent to CMMI and I'm going to turn it over to Elena. Great. Thank you. I will share my screen here in just a second. Okay. Can everybody see the presentation? I can. Yes. Great. So the purpose of this letter to CMMI and CMS is to acknowledge the effects of COVID-19 on the all payer ACO model to the Medicare ACO initiative and ultimately our hospitals as the barriers of risk and other participants participating in this model. So I think we kind of talked about some of these challenges last week. But, you know, together, all three signatories have started developing this letter to request federal support in two key areas. The first is around the distribution of resources to support hospital solvency during the COVID-19 pandemic. And the second is about the evaluation of the not all payer accountable for a care organization model. So the first, we'll kind of talk about the first series of requests. So before COVID-19, Vermont hospitals, independent practices were already experiencing financial challenges should not be surprised to the board. So statewide demographic trends, growing supply costs, rising pharmaceuticals, workforce shortages among those key drivers. You know, as you know, in FY-19, half of Vermont hospitals experienced operating losses with six of 14 having experienced operating losses for three or more consecutive years. So we were already kind of uneven ground to begin with before this pandemic settled in. In preparation for COVID-19 revenues have been seriously compromised by the cancelling of elective and non urgent procedures while expenses have held steady, causing additional financial strain in the near term on our hospitals and providers. So while many of our providers participating in the model do see these fixed payments, it's only roughly about 25% of their revenue stream at, you know, as in best case scenario. So it hasn't been enough to cover those losses. So, you know, as we grow to scale and we can get more fixed payments in the system, you know, this will look better, but right now it's we're still not there yet. So the result is a rapidly declining data cash on hand. You know, many of our hospitals started with less than 30 days operating cash, and this has been decreasing in our experiencing negative margin. So if we assume 50% loss of net patient revenue, this means the corresponding loss of 115 million in operating margin each month across the hospital system. And some of our hospitals in particular have said that they expect to see reductions of more than 70%. So that would mean, you know, disproportionate effects that may be felt across the system. So while we are monitoring the financial health of our hospitals, you know, there's still some concerns and we want to do everything we can to make sure that every dollar is going to the right place right now. So our first series of asks is about adjusting the Vermont Medicare ACO initiative. So invoking the exogenous factors clause in the Medicare contract with one care. This is not a contract between the state and the federal government. It's between Medicare and one care Vermont to allow the 2020 benchmarks to be reevaluated as appropriate. So we do have some say over the benchmark, but this is really their contract and we can provide guidance and recommendations for what that should look like. So the rationality here is to ensure that providers are not financially harmed or penalized for forces that are outside their control. The effect of this pandemic could not have been contemplated when providers agreed to participate. So there are no protections in this agreement for providers in light of a pandemic, as that is not something we were thinking about. So the second is to eliminate downside risk and adjust the initiative to these shared savings only for 2020. This would increase fiscal certainty for hospitals who bear the risk of repaying losses if the hospital underperforms and would allow one care Vermont to distribute much needed funds, providers that would otherwise be required to purchase reinsurance against that downside risk. The third adjustment to the Vermont Medicare initiative would be to recommend 2020 as a reporting only here for the purposes of quality measurements. Last week we approved that one care in their budget order could reduce the amount of this reserve that they're holding aside, but this would make it so that they wouldn't have to actually pay out those funds back to the federal government. Yeah, that the funds could be released back to the network. So the rationale here is that the funds would be released, but we expect the quality measurement given COVID-19 will kind of have a negative impact on the system. So that's why this is an important, an important ask. The fourth adjustment would be to allow the 2020 AITBP to be a true capitated payment. Should the fee-for-service equivalent be less than the AITBP, which is possible given the reduction in utilization across many existing services that we would otherwise count in the fee-for-service equivalent. This would hold providers harmless for severe unanticipated swings in utilization as just described. The last adjustment would be to provide an extension for the submission of the final Medicare provider participant roster for 2021. This would enable providers to continue responding to COVID-19 instead of kind of thinking about administrative tasks and analyzing whether or not they want to participate in the future. It would also allow hospitals to understand their financial position before signing up or not over the next year. And then, you know, hopefully this will happen after the peak of responding to COVID-19 so that they have time to kind of weigh those decision points. And, you know, this extension will also help us as a State Achieve Gales Weekend really get providers the opportunity to think about it. I'll stop there. Are there any questions on the Vermont Medicare ACO initiative request? Questions from board members? Yes, Maureen. I just have one which is unlikely that this will happen, but on the fourth one where it's allowed in the 2020 AITB to be the two-capitated payment should fee-for-service be less. In the rare instance that it would be possible that it's more, you know, we'd want to then have that be reconciled as well, right? Yes, that's exactly so. So I would just make sure it's, you know, we don't expect that, but if it should happen because the costs for COVID come in and end up, you know, being higher than what they lost elsewhere, just to make sure we're covered is all I'm saying. Yep. Absolutely. I believe the language specifies that, but I'll go back and double check the letter just to make sure it's extra clear. Great. Thanks. No problem. Other questions from the board? So the second series of masks is around just additional funding, so allow OneCare Vermont to keep funds that are due to CMS or duplicate payments that were made to hospitals in 2019 and exclude these payments from year-end reconciliation of the ITVP. This would allow OneCare Vermont to deploy these funds that they already have, you know, on site to Vermont hospitals to use immediately. The second bullet under the second series of requests is to forgive repayment by Vermont hospitals if any unearned advanced shared savings for 2019 should Vermont's unearned shared savings in the Medicare initiative be insufficient to cover the advanced shared savings that would support the continuation of blueprint slash CHT, sorry, that was used to continue blueprint. So those services are not going away. We just want to make sure that OneCare is not then paying more on top of this. So any further outflow of funds at this time could seriously inhibit Vermont hospitals' ability to respond to the excellent healthcare crisis. So any difference between advanced shared savings and what was earned would come from hospitals. So I think that's an important thing to remember. And the last ask is if there are any other additional funding opportunities for participating providers who would welcome that support. So we want to make sure that we come out the other side of this pandemic with, you know, a continual high quality healthcare system, even not just hospitals, but other providers as well. Any questions on those two buckets? Questions from the board? Evaluation of the all-payer model. This is the second category of the quest that I will be referencing this letter. So the Exogenous Factors Clause section 19 of the agreement. You know, we have the opportunity to invoke this Exogenous Factors Clause to be taken into consideration when assessing performance on the all-payer or Medicare total cost of care per beneficiary growth target. The financial metrics in particular. And then through that process, we shall explain the impact of such factors on the model, including any recommendations as to how CMS should adjust the model to reflect these exogenous factors being COVID-19. So any such adjustment will be at the sole discretion of CMS that will have to gain approval. And there's this idea that we have to quantify the effect. So, you know, I think the whole premise here is that, you know, while we don't know exactly what those effects are and cannot perhaps quantify them at this time, we recognize that there are, there will be likely many adjustments, as many assumptions that this model was built on are totally out the window in some cases. So I think, you know, this is more just to alert our federal partners that we will be making this request as the circumstances of this pandemic are far outside the factors contemplated during the model design, and we expect to have adjustments. So the request is to continue to monitor financial impact and we will formalize what that will look like as we get more information. And we want to make sure that, you know, Vermont can continue to prepare and deal with COVID-19 and that this doesn't affect how we are evaluated for implementing this model. As many of the utilization patterns are expected to shift not only now, but into the future. So this might not be just a one-time request, but may continue to crop up in future years. You know, we could see disruption of inputs and supply chains now and in the future. It might look very different if many businesses, you know, kind of go out of business and, or that remains to be seen, but we'll continue to monitor that. As it relates to the quality targets, while the Exoptionist Factors Clause is really just about financial targets, we expect this also to apply to quality. Along with the Medicare contract, we would expect that the quality performance for 2020 for the all-payer model itself be considered reporting only, so this is the statewide target. So, you know, there has been, there's precedent, you know, CMS has made adjustments to quality performance requirements and the task for other kind of extenuating circumstances like wildfire, fires and hurricanes. So while those are generally regional and have a very prescriptive method for adjusting, we, you know, we believe there might be something different that they could do, but that the quality framework should also be addressed during this time. So we expect that COVID-19 as well as some of the, you know, bold actions we've taken to impact our performance, as I said, you know, providers and facilities are really focused on delivering essential services. And I've, you know, are not so much focused on preventative and comparably less urgent follow-up services that we would otherwise want to, you know, make sure happen in a different environment. So I think, you know, what we'll see in the future is maybe some, you know, discrepancies on our quality and population health targets that we would otherwise hopefully be making progress on in the agreement. So I just want to kind of let you know where we are now. A draft of this letter was circulated. I think the board should have all seen it by now to AHS and to the administration. If this letter and its contents and spirit are, you know, of your approval, we, the staff would propose that you vote to designate board staff to collaborate with AHS and the administration to finalize the letter. We would expect that it wouldn't materially change. And if it materially changed, we'd come back before the board. And so the chair of the board to sign and submit the letter to CMMI or CMMS on behalf of the GreenMap care board. So then, you know, the work would be to finalize, submit the letter, and then to work with one caregiver month to operationalize any approved changes that require in partnership. And that's all I have. Any questions? Okay. Questions from the board members. That's the last slide, isn't it? Yeah. I have a question. I just have a comment in that I'm glad the, you know, the initial draft this letter that I saw was emphasized as it should, you know, hospitals and this later version, which seems to have been scrubbed by everybody includes other providers and independent practice folks. And I'm glad to see that because I think there is as dark as this period is, there's an opportunity here for independence and primary care providers to see the ACO in action under stress. And, you know, if you look at the list of providers and the numbers that are aligned with the fixed prospective payment, the independence, it's very few. And here is a situation where there's a benefit of being a more active participant in the ACO. And I'm glad to see that now the concept of independent providers and other providers are kind of woven through the language in the letter. And hopefully as we come out the other side of this, we will have more and more people signing up for the fixed prospective payment. Offerings that the ACO has. Thank you, Tom. Other members of the board. No, I guess I would just thank Elena and others who have worked on this. I think, you know, a lot of viewpoints and perspectives were considered and incorporated into this letter. And I think it's a really solid ask of our federal partners to help us out here. So thank you to everybody who worked on this. Robin or Marine, do you have anything? No, I echo Jess's comments and Tom's comments, but I don't have anything else. Okay, then I'm going to open it up to the public for comment. Does any member of the public wish to comment? Devin Green from Vaz. Go ahead, Devin. Thank you. I wanted to thank the board on behalf of hospitals for this letter. This is a very comprehensive letter that thinks about the short term and the long term and looks at retaining available cash to help with cash flow. And it's a very comprehensive. So we really appreciate your effort. Thank you. Thank you, Devin. Other members of the public who wish to comment. This is Sarah Berry, One Care Vermont. Hi, Sarah. Go ahead. Thank you. I want to echo the sentiment. We very much appreciate the speed and the thoughtfulness with which this letter has been pulled together and it's being prepared to be submitted. We feel like the times that we're in are so unprecedented that creativity and flexibility and thinking about multiple avenues for providers across our continuum of care is incredibly important. And we think that this will go a long way in helping to identify where there are specific opportunities to leverage strategies that either have been put in place and can be addressed differently or to identify new avenues for us to work together on. So thank you very much. We look forward to continuing conversations as this moves forward. Thank you, Sarah. Is there any other members of the public who wish to comment? Hearing none. Robin, would you like to make a motion? Of course. I move that we designate board staff to collaborate with AHS and the administration to finalize the letter and for and to delegate responsibility to the chair for signing and submitting the letter. Along with staff. Okay. Is there further discussion? Mike Barber to call the roll. Member Pellum. Yes. Member Holmes. All right, I'll mute. Yes. Member Yousafur. Yes. Member Lunge. Yes. And Mr. Sharon. Yes. Thank you, Elena. Thank you for all the hard work that's been done. Big shout out to Ina Bacchus for her hard work on this as well. And the next item on the agenda is going to be the 2018 health outcomes. And again, we're going to go back to Elena and Michelle. Michelle, are you on the line? To share my screen. Okay. I'm going to get it loading. So that's a good sign. All right. Let's try that again. It didn't like it. So we're going to do it a different way. So hang on one second while I try to get it to work one more time. I can always share it. Michelle, I think I have it up. So let me just. Yeah, it was because my camera was on. This will look a little funny because I'm not using my fun PowerPoint tools, but so as the slide sort of indicates here, I am here to talk to you all about the 2018 statewide health outcomes and quality of care results, otherwise known as the quality framework for, again, performance year one of the model 2018. And understanding these results, we, you know, sort of wanted to preface this by saying, you know, this report truly focuses on results that were produced based on a mutual understanding of the technical changes amendment that was in progress at the beginning of 2020. As such, it codifies memorandums and other changes negotiated between the state of Vermont and GMMI between performance years one and two, the 2018 and 2019 of the agreement, sort of in light of COVID-19 pandemic requiring both the state and national response. The amendment has been paused as priorities have really shifted to address more pressing needs. Given the mutual understanding that we have reached and considering full transparency, the GMCB wanted to submit this report based on that mutual agreement between the APM signatories. So everything that you are going to see in terms of results is based on the presentation that we gave to the board on February 26th. As a reminder, a special commentary was open following that presentation and no public comment was received. So before I dive in, I just kind of want to remind folks that these results are going to be shown divided into the three domains for which we're scored on for the agreement. There's population level health outcomes, healthcare delivery system quality targets and process milestones. And then within each of those three domains, measures are further divided into those three overarching goals, which are increasing access to primary care, reducing prevalence of chronic disease and reducing dexterity to drug overdose and suicide. So, and again, just as a reminder for performance years one and two of the agreements for 2018 and 2019, the agreement sets an expectation that results will improve over baseline. So with that said, I've highlighted throughout the results in green where we've met or exceeded targets and in yellow where there may be some cause for concern or something to really continue to look at as we explore this further. All of the unshaded- So, Cheryl, you're still on slide two on the screen. Have you moved forward? I have not yet. Okay. Just shortly. Yes. So all of the unshaded cells utilize 2018 for base or don't have final 2018 data. Therefore, there's no way for us to really rank them against baseline performance. So with that, I'm going to go into the population level health outcomes target for those on the phone. This is slide three. So again, based on that preliminary agreement in an effort to more accurately measure performance across the population, the data here has been updated to utilize 2017 as a base where applicable for performance years one and two. Again, the expectation is that we're going to show improvement. So what I wanted to do here is sort of walk you through the results that we have. Again, green is where we're to be sort of meeting that expectation. Yellow is some potential cause for concern, but again, a reminder that the targets are for 2022. So we do have some time to reach those. And then within each of the three goals, I really wanted to call out one or more as you'll see. This is where my animations would have been really cool, but that's okay. So I want to call out one or more sort of results and just talk through them a little bit. So for the population level health outcomes target, I'm going to dive in and talk a little bit about the deaths related to suicide statewide and sort of highlight some talking points on that measure. So the model itself set a statewide goal of 16 deaths to suicide for 100,000 Vermont residents by the end of 2022. The rate of deaths did increase slightly from the 2016 base year, which you can see with 17.2 to the current reported year, which is showing at 18.3. When viewing progress related to state rankings, however, Vermont is currently 19th in the U.S., bringing the state closer to our 20th in the U.S. target, which is an alternative metric for assessing progress on this measure. Again, you know, something that we all know, but it never hurts to be reminded, Vermont's small population makes this measure incredibly volatile. One or two, an additional death can result in an increase in this rate. I will note that noticeably significant change has occurred over the past 10 years on this measure. And just to sort of call out utilizing this measure to highlight some significant data lags in obtaining performance or information. So for this measure in particular, the results are based on medical record review. And so since the data for Vermont deaths require that data for this measure is quite lagged. And then I just wanted to highlight briefly, you know, the state has focused several initiatives on suicide prevention and an effort to increase awareness and outreach and hopefully reduce deaths. For example, we have the Zero Suicide Initiative and the GMCB staff here will continue to monitor these programs as the model progresses. So before I move on to the next set of measures, does anyone have questions on these ones here? Questions from any member of the board? Question, but I just want to comment that I've been seeing reports of higher suicide rates since the COVID-19 pandemic has started. So I think some of our efforts in terms of having, you know, recognition of this pandemic as an exogenous factor in the coming years as we evaluate our success on these quality metrics is going to be important. And, you know, I think the state is doing some, you know, great outreach on mental health and things like that during this pandemic, but I am worried. Yeah, I agree. I've also heard that. And I think one of the things that we'll have to remember is sort of the timing of the COVID is literally smacked up in the middle of the agreement, right? So 2020 is year three. And so we'll be able to have two years in theory of trend data and then this sort of exogenous year we're hoping for as Elena talked about earlier. And then two years after that kind of we'll see how things shift. But I think I absolutely agree and trying to prepare for how we look at all of these measures as, you know, they might have different outcomes related to the COVID pandemic. What's especially tragic is seeing some of the high profile cases worldwide where healthcare workers have committed suicide in response. Yeah. Hopefully that doesn't happen here in Vermont. Absolutely. Yeah. Anyone else before I move on? Set of measures we're going to talk about are the healthcare delivery system quality targets. So again, data were updated here to use 2017 as a base where applicable. And then for the measures that are ACO specific, which is many of the ones listed on this page here. We updated the base to be a more accurate comparison throughout the duration of the APM agreement, especially within the ACO population as 2018 was the first year of the next generation multi payer ACO initiative. So we wanted to highlight that here and really that did update all those baselines to 2018 to be able to have that trending over time. So I will say that you'll see many of these are unshaded and that is mostly due to the fact that if 2018 is the base, we can't necessarily assess progress towards our goal. So again, I wanted to highlight a couple of measures here. There's only two stars on the screen. I actually am going to talk about three of them. But so one is the growth rate of mental health and substance abuse related emergency department visits. And specifically, this is looking at the rate of growth from one year to the next. So you'll see each year, we've got the primary to 2016 to 2017. We had a rate of 5.3% and in 2017 to 28, that rate increased to 6.9%. This measure utilizes Vermont Hospital Uniform Discharge Data. I've identified those at a primary diagnosis of mental health or substance abuse. One thing I did want to point out is that additional information and analysis that I have conducted with this data shows that a greater proportion of people presenting to the ED with a primary diagnosis, health or substance abuse are being admitted at a higher rate than those general ED visits. So this is sort of suggesting that Vermonters are seeking appropriate treatment and are in fact admitted for inpatient treatment when they're seeking care in the ED. So as a comparison, we don't have it up on this slide, but the total amount of ED visits that results in an admission, an inpatient admission, is 11%. When you look specifically at those ED visits for mental health or substance abuse, that admission rate is 17%. I also wanted to call out, we'll have to, given the current COVID-19 pandemic, we'll probably have to revisit this in 2021. But in the last year's hospital budget non-financial reporting, a lot of the hospitals responded to this measure and talked about their programs that they've begun to initiate in their emergency departments for mental health and substance use disorder treatment. You know, some examples from last year included designated staffs embedded in the ED to connect patients with primary care. Should they not have an existing provider, medication-assisted treatment initiation in the emergency department and increasing specialized ED staffing and training to assist patients who present with mental health or substance use conditions. In addition, we know that there are hospitals who have looked to transition existing ED spaces into safe and private areas for patients who are awaiting admission or transfer for mental health and substance use conditions. So again, since we've sort of put on pause this year, the non-financial reporting from the hospitals, I think it's something we can certainly revisit. But I just wanted to point that out for you all. The next measure I'm going to talk about is the diabetes hemoglobin A1C, so HB A1C in poor control. This measure is specific just to those Medicare ACO-attributed lives. But the reason I wanted to call it out is to just give it a note that it does combine, the results shown here combine two measures. One is ACO number 27, which is that ACO or the hemoglobin A1C, poor control. But it also is a composite measure and it includes ACO 41, which is a diabetic eye exam measure. For 2018, these two measures were part of the diabetes management composite. Looking forward, it appears that for 2019, these have been disaggregated for the Medicare Start Saving Program, so it's likely that this will fall in suit. Since the agreement itself is specific to the A1C poor control, which is number 27, we'll continue to work with our federal partners to update this rate that you see here and produce a percentage for the A1C poor control only moving forward. So I know that's a lot to say. I just wanted to call out that the measure that you're seeing here does not directly correlate to the language within the agreement. But that is currently how Medicare produces the rates. So there's one more on this page that I want to talk about, and my star isn't showing up, so I'm going to put a bullet. We're going to talk about engagement of alcohol and other drug dependence treatment. And I'll do this sort of briefly. So the agreement sets forth a goal of increasing initiation and engagement rates by at least 5% for initiation and 10% for engagement respectively. While the state's performance on both initiation and engagement components of the measure are in line with national trends, the absolute percentage of people counting as engaged in treatment is very low. The state's Medicaid agency, SEVA, has explored and developed modifications to the measure that more accurately capture treatment activities underway in Vermont, including residential and MAG type services. In SEVA reports, the IET measures, there are two modifications that they apply that are captured the services received by their beneficiaries. And when you look at these two modifications results in engagement rates for 2018 increased to 23.9 for Medicaid. So the GMCB is going to work with the MMI to decide if these additional modifications can be applied to the statewide all-payer ACO rate that's included in our annual report. Any questions on these measures before I move on? Any questions from the board? So we're going to talk about process milestones. So again here, baselines are 2017 for statewide measures. And for those measures that are ACO specific, 2018 will serve as the base year. As you can see here, there's a lot of green on this page. I thought Jeff Holmes might like this one. So there, again, green is where we're meeting or sort of surpassing our target for the end of the model. So these are pretty big to have achieved in just one year from base. So I wanted to sort of highlight those and then I'll talk about a couple of measures specifically here. One of the measures is the percent of remote providers checking the prescription drug monitoring program before they prescribe opioids. So just a couple of highlights here. The rate of queries by prescribers, this is how it's calculated, it's complicated. Rate of queries by prescribers who have written at least one prescription relative to the number of unique recipients of at least one opioid prescription has increased significantly from the 2007 baseline year. 17 baseline year, excuse me, which was 2.19 to performance year one where you're saying that 3.1 rate. Most notably was the reduction in unique recipients. So it declined 16% from 2017, which just over 86,000 unique recipients. And in 2018, as you're seeing here on our denominator, you're looking at 72, just about 72.5 right here. With a number of prescribers or delegates checking and the VTMS before prescribing increasing by 19%. So we're seeing a very steady increase here in the usage of the program. It's led to a very dramatic change in the reported ratio. And so just a couple of drivers of this change to highlight can be tied back to the Vermont prescription monitoring system rule, which implemented the system itself. And that was effective July 1, 2017. In addition to the rule, the Department of Health, Alcohol and Drug Abuse programs have been working to deploy systems enhancements that include prescriber reports, clinical alerts, an increase in educational and training opportunities for prescribers and providing education to the general public about the harm of opioid misuse. So that was just a really important one to highlight. I thought, you know, just see that increase be so drastic in just one year. The next one I'm going to talk about here is the percentage of Medicaid enrollees aligned with the ACO. So this is the statewide Medicaid rate that's shown here. So the APM sets a goal for the proportion of Medicaid beneficiaries aligned with the ACO. The percentage should not be more than 15 percentage points below the proportion of Medicare bennies also aligned to the ACO. In 2018, the percent of ACO-aligned Medicare beneficiaries was 25.2 and not using January 1st enrollment. For Medicare, 35% of beneficiaries were enrolled, marking an approximate 10% difference in the results. The APM agreement anticipates that ACO scale will increase over the life of the agreement with a more significant trajectory after PY1. And again, you know, that gradual ramp up from performance year one is expected and was an intentional design of the scale target. But I did want to highlight that we are currently meeting the expectations of that goal. Any questions on these ones? Questions from the board. One more slide. So again, just sort of framing this in terms of looking forward to truly understanding the impacts of shifting priorities due to the COVID pandemic and the long-term effect on quality measurement and our public reporting. Two things really popped out in my mind, which you heard Elena address earlier, the request that we're putting forth to CMMI in regards to potential reporting requirement changes for the ACO. And then additionally for the state's report for the statewide health outcomes and quality of care report, which again won't be produced until the end of the following performance year. So it won't be released until the end of 2021. But just kind of anticipating that the changes and the impacts that will need to come from that. And that's all I have. Okay, are there any questions from the board members? Hearing none, I've been open it up to the public for comments. Any member of the public wish to comment? This is Kathy Maloney. I have a question for you, Michelle. Let me survive a slide right here on slide four. Yes. On the measure around the growth rate of mental health and substance abuse rate related ED. Yes. I think that says the type. Sorry, I can't see that. No, that's okay. This COVID crisis is going to fundamentally change the many aspects of our lives, particularly around healthcare delivery. And one of the things that is really taking off of course is telehealth to increase access without having a patient physically have to present him or herself to an office or a hospital. And there may be some opportunity here and some learnings here in this one. We're where we may be able to have better outreach to patients with mental health crisis or prescription issues or other other questions to sort of reduce the chance that they be compensate and get admitted to the hospital. So I just wanted to provide that comment to folks. And the other one was a technical question here. Is this measure all comers or is it pediatrics adults? No. For the still talking about the rate of growth. Yes. It's any it's anyone who in who enters over month hospital. So it's pediatrics as well. Yes. And the reason I ask is that there is quite a national increase. Unfortunately, in the number of pediatric patients with behavioral health issues. I'm wondering how. Yeah. We can see that in the data that we receive. Also, so through the hospital discharge data that we, you know, I calculate this rate based off of data that we receive. And this is a complex comment, but this is based off of the CCS five category, which is mental disorders. I believe is what it's technically called. But you can see the breakout by age within that. When you look at it as a statewide level, not necessarily at a hospital level, but you can see one of the categories of specific to pediatrics. If I'm remembering correctly, and you can really see that growing. Unfortunately, the other thing I'll say about this is that this measure itself has a saved approach. So by performance year five, CMS's intent was to have this rate decreased to 3% by that time. You know, I think I'll channel my best Pat Jones here as I was not the one who negotiated these, but this was a measure that nobody ever really liked. Because if you want people to receive treatment and have access to care, if the ED is the place that they need to go to get that. You wouldn't want to discourage someone from that. So the reduction in the rate sort of seeming like perhaps you are discouraging people from taking treatment. It's not a favorite. I don't know that it's one, quite frankly, that we might ever meet through the duration of the agreement. But I do agree that sort of this expansion of telehealth sparing times of COVID might really sort of help us in that. And that people might realize that there are other ways to access these types of treatment. Thank you for that. And then my last comment is just to thank you that these are very complicated data sets and tough to get through. And I wanted to thank you for giving us the highlights of this in a very thorough manner. Thank you. Thank you. Oh, sorry, a follow-up question to that. Certainly. I'm just wondering, are we going to be able to count or measure telehealth visits related to these measures for this year? That's a really good question that I don't have the answer to right now. I would imagine we might, you know, in looking at our clean data is something that would show up. We might have to rely a little more heavily on our provider partners there to sort of think about that for this year until we move forward. But that would be a question that I would kind of direct to someone on the analytics team, so like Lindsay or Sarah Lindberg, to see if they know how those telehealth visits show up in V-Cure so to be able to better capture it. But again, the good thing about the VUD data, the discharge data, is that it's everybody. V-Cure, of course, is a little bit more limited. Okay, thank you. This is Kathy. I have received various announcements and mailings from CMS about expanding the codes for telehealth visits, which I think is for this purpose as well. So I think we should be able to get that information. Thank you. Chair Mullin, this is Kathy Fulton. Could I add some information? Sure, Kathy. Thank you. Thank you all. Michelle, great presentation. And to answer both the other Kathy and Jessica, VPQHC is working very aggressively and diligently with regional partners on telehealth disseminating, broadly disseminating coding reimbursement information. All the updated changes were collaborating with the Northeast Telehealth Resource Center to schedule what's called office hours so that providers can call in and get that information. We had a very large presentation done yesterday, currently posted on the VPQHC website with details by insurer information on coding and reimbursement information. So to answer the question, yes, it should be able to be tracked. The information is out there. We want to keep encouraging folks to get a hold of that information. And, you know, our partners, Vice State, VODs, the list goes on and on. NETRIC can help support providers to make sure these telehealth visits are being accurately captured and coded. Thank you, Kathy. Thank you. Other members of the public hearing none. Thank you, Michelle. I just want to echo what Kathy said earlier. You really were able to summarize a lot of information in a very cohesive manner. And we really appreciate all the efforts that you have been doing. Thank you. Thank you, Kevin. So at this point in time, we're going to move on to a review of our CON process as we deal with COVID-19. I'm going to turn it over to Mike Barber. Thanks, Kevin. So this is really following up on some discussion that last week's board meeting. As you know, H742, which was enacted on March 30th, 2020, gives the board the authority to waive or permit variances from state laws, guidance and standards with respect to various board programs or processes, including the Certificate of Need program. And the Board's waiver authority extends for six months after the termination of the declared state of emergency in Vermont, resulting from COVID-19. So based on the discussion at last week's board meeting, the legal team and Amaran specifically, so thank you, Amaran, drafted another CON bulletin that if it were adopted, would temporarily waive the need for CON for certain categories of COVID-19 related health care projects. So I don't have a PowerPoint presentation or anything, but I will, if it's helpful, just go through the draft that's supposed to be on our website and just explain the thinking. That would be great. So the first section of the bulletin just gives background information and sets forth the legal authority for the waiver. The second section defines the projects that are covered by the waiver. The emergency procedures that the board adopted in CON bulletin 002, if you'll remember, created an expedited process by which the board would issue time-limited CONs for any new health care project that enhances or supports the state's ability to respond to the public health emergency. And the idea with this bulletin would be to temporarily waive the need for the board to review and approve a subset of those procedures and to figure out which projects to include in this temporary waiver. What we did was we looked at what the federal and state governments are currently doing and what they think is or may be necessary to respond to the pandemic. So subsections A and B really relate to federal actions and specifically to 1135 waivers. So let me just take a minute to describe what those are. In the event the president of the United States declares a major disaster or emergency, the U.S. Department of Health and Human Services may declare that a public health emergency exists in an affected state. Once a public health emergency is declared, section 1135 of the Social Security Act authorizes the secretary of HHS to temporarily waive or modify certain Medicare, Medicaid, CHIP, and HIPAA requirements. And the waiver authority is really to ensure that sufficient health care items and services are available to meet the needs of beneficiaries in the affected area and to ensure that health care providers can, in good faith, be reimbursed and not subject to sanctions for non-compliance with current regulations. So section 1135 waivers can be issued to individual health care providers or to states on a case-by-case basis, but they can also be issued on a blanket basis to all similarly situated providers in an area. So subsection 80 of the bulletin is covering situations where a health care facility has applied for and obtained an 1135 waiver to implement the project. And, you know, that waiver allows the facility to undertake certain activities that don't comply with CMS regulations. The need is really a big part of what the federal government looks at when they're deciding whether to issue one of these waivers. And so we figured that if the federal government has already found a need in the context of a declared emergency, it probably makes sense to hold off on CON review of that project until the emergency has subsided. Subsection B of the bulletin, sorry, covers the blanket waiver situation. So there were blanket waivers that were recently implemented in response to COVID-19. These are national waivers for a national emergency. And they cover a variety of providers, including hospitals, skilled nursing facilities, home health agencies, hospice providers, durable medical equipment suppliers. And most of the things that are permitted by these 1135 blanket waivers would probably not trigger CON review. They're doing things like granting variances for things relating to employee training, reimbursement limits, those types of things. But there are some waivers that allow hospitals, psychiatric hospitals, and critical access hospitals to use non-hospital buildings and spaces for patient care and quarantine sites. And that also allow long-term care facilities and skilled nursing facilities to use non-SNF buildings temporarily in the event there's a need to isolate COVID-19 positive patients. So these specific activities under the blanket waivers would require state authorization, which in Vermont would be given by the Division of Licensing and Protection under Dale. And those activities also have to be not inconsistent with the state's emergency preparedness or pandemic plan and what we're trying to capture in this subsection B is these activities under the blanket waiver. In subsection C, we're trying to cover those projects that are part of the state's coordinated response to the pandemic and they're being directed by the Department of Public Safety or the Agency of Human Services. And then subsection D is covering the development of a hospital that will be constructed or operated by the U.S. government or an agency thereof. So this would cover sites that may be set up by the Vermont National Guard and just make very clear that these are not going to be reviewed by the board, even if they happen to hit a jurisdiction threshold. The next section of the bulletin deals with the duration of the temporary waiver. So the waiver would last for the duration of the declared state of emergency in Vermont for the COVID-19 pandemic and for six months thereafter, which is basically the extent of the board's waiver authority. You know, it's unclear how long the federal 1135 waivers will last, at least the blanket ones I believe are tied to the national declared emergency, but we figured the safest thing to do would probably be to go six months out even though I don't think most of these projects would be extending that long. If after the waiver period ends, the healthcare facility wanted to continue the project, they would have to apply for a CON and go through the normal review and approval process unless the board specified otherwise the facility could continue to operate the project while the CON application is pending. I struggled with this piece a little bit. I mean, the default here could be reversed. I mean, the language could say that unless the board allowed it, the facility would not be allowed to continue operating the project, but I believe we use this same language in the current CON bulletin 002. So for consistency, I went with this. The next section requires a limited notice to be submitted to the board except that the kind of government-led projects that are described in C&D above will be excluded from having to provide notice. The second to last section allows healthcare facilities to submit certain documentation in lieu of notice to the board. So either the 1135 waiver application and CMS approval for the individual 1135 waivers or the state survey agency application to the Dale, application to Dale, licensing and protection for the blanket waivers that I talked about. And then the last section just makes clear that we can ask for updates on information during the temporary waiver period. We did reach out to our partners at AHS for their feedback on this as well as the healthcare advocate and representatives in the provider community. And I didn't hear back from everyone, which is understandable given the short notice but I gave folks but for the folks that I did hear that from, which I do incorporate those comments to the greatest extent possible. So that's all I had. Do you guys have questions? Questions from the board? And I just had a question on when we talk about if an entity wanted to continue with this, I know they have from when they applied or they have them six months after the emergency was declared over. But I wonder if we should just put something in. I mean, you know, as soon as they know they may want to continue this, that they need to come forward and... Maureen, you're muted for some reason. Yes, someone must have muted me. I didn't touch it now. No, so the question is really just, you know, I'm in full support of this. It's just at the end, if somebody wants to come back, they do have to get approval. And if they want to do that, we're not really clear on when they have to come back, how soon they have to come back. And so, you know, they're given six months after the end of the medical emergency is declared over. And then it's like at some point after we let them continue and then they have to come in with their CLN. So I just wonder if we can firm that up a little bit. As soon as they know that they're going to want to continue, they really should start the process with a reasonable amount of time. That makes sense. So require a notice to the board as soon as they know that it's something they would like to continue. I mean, I would think they'd have to have an application to us before the six month waiver period ended. But are you thinking sooner than that? I would be okay, but it's just not clear. It really just says they can continue using it, which I think they should be able to. And then they have to apply. We just haven't really set any parameters. So once this ends and then they have six months after that, I just think put in, you know, once they realize, hey, they're going to continue to use it, they should be putting in their informal application. Okay. Other members of the board, Jess, if you're speaking, you're muted. I'm not speaking. I'm shaking my head. No. Okay. I just want to thank Mike and Amron for all their hard work and very quick work, including some weekend work getting this done in the last week. Thank you, Robin. Not hearing anyone else from the board. I'm going to open it up to public comment. Does any member of the public wish to comment? Devin Green from buzz. Go ahead, Devin. Thank you. I want to echo member lunges comments, thanking Amron and Mike for their hard work on this. We really appreciate the streamline process and considering projects that need to apply through the DLP as deemed as well. So really appreciate that effort and that will help give the hospitals a lot of flexibility going forward. So thank you. Thank you, Devin. Is there other public comment hearing none? Robin, would you like to make a motion? Yes. I move that we approve bulletin three with a modification to require notice of continuation of projects as soon as practical, which we will let Mike work next. I'll second it. Is there further discussion from the board? None. Mike Barber, if you could call the roll. Member Yusufer? Yes. Member Kellam? Yes. Member Holmes? Yes. Member Lunge? Yes. Mr. Chair? Yes. Thank you, Mike. Thank you, Amron. You're welcome. At this point, is there any old business to come before the board? Chairman, this is Michelle. I apologize. This is not old business. I neglected to mention in my presentation that the final report in its entirety for the statewide health outcomes and quality of care is available on our website, both under this meeting and under the all-pair model page. Thank you, Michelle. Thank you. Board members, is there any old business to come before the board? Is there any new business to come before the board? This is Mike. I have an item of new business to bring up. Go ahead, Mike. So one chair, representatives reached out to me the other week and asked for some guidance on how to interpret a governance-related requirement in our ACO oversight rule. It's dealing with a section of the rule that talks about representation on the governing body for commercial insurers that have a certain Vermont market share. And, you know, it isn't very clear how to apply that provision. And there are a lot of variables kind of at play, including what data source should be used, what time period are we looking at, what markets are we talking about? How are we calculating market share in terms of premiums or lives, that sort of thing? So I had a conversation with them. I think we do need to issue some guidance on this now that OneCare is kind of expanding its footprint in the commercial space. And, you know, it's also, so I guess I'm just looking to the board for some direction. Is this something that you guys would like to delegate to me to issue some guidance on in terms of how to calculate this? Would you prefer that I develop something and bring it back to you with a presentation and board approval or how would you like to move forward on that? Well, just speaking as one member of the board, I think it would be totally appropriate to delegate it to you and your legal team to come up with the guidance. But how do others think? Yeah, I agree with that as well. This is Robin. Me too. It's very similar to other very technical areas that we've delegated in the past. I'm fine with that as well. And it makes sense to me as well. When I read the section that there is some kind of overlapping nuances there that I don't think I'm prepared to vote on yet and I would appreciate Michael's timely review of those nuances and come back to us with something that we're the whole integration with the 75% rule and this 5% rule and who does the 5% rule is more clearly sorted out than it is now. Mike, do we need to vote on this or can I just delegate it to you? No, I think there would need to be a vote. Robin, would you like to make a motion? I'd love to. I move that we delegate interpretation of the governance related part of our accountable care organization rule to the legal team. Is there a second? Second. At this point, I'm going to open it up to any public comment. Does anyone from the public wish to comment? Yes, this is Julia shopping the healthcare advocate. Go ahead, Julia. We would just ask for the opportunity to review Mike's guidance before it is issued if that's a possibility. And provide feedback. Yeah, I can be in touch Julia. Thank you, Mike. Anyone else from the public hearing none is there any further discussion from the board hearing none might could you call the roll. Member Bellam. Yes. Member Yusufer. Yes. Member Holmes. Yes. Member Lunge. Yes. Mr. Chair. Yes. Is there other new business to come before the board at this time? Hearing none is there a motion to adjourn? So moved. Second. Mike, if you could call the roll. Member Lunge. Yes. Member Bellam. Yes. Member Holmes. Yes. Member Yusufer. Yes. Member Chair. Mr. Chair. Yes. So I just want to thank everybody. These meetings continue to be going fairly smoothly on Skype. I'm glad we didn't choose Zoom based on some of the headlines we've seen nationally. But I just want to thank everyone and I know most of us are longing for the days when we can actually see somebody in person. But at this point it has been working well and Vermonters have been doing an incredible job at trying to flatten that curve. And very proud to live in a state like Vermont where people truly do care about others and are following the guidelines set out. So with that, have a great afternoon everyone. And so long. Bye.