 We'll get started. I'll call to order the Green Mountain Care Boards hearing of January 31st, 2024. We're down a couple of personnel today. Dr. Merman will not be here today, so there will be four board members. And then our executive director, Susan Barrett, is out today as well. So we'll skip the executive director's report and we have two agenda items. The standard qualified health plan design proposal by the Department for Mod Health Access. And then the health resource allocation plan update by GMCB. We have a hard 345 stop today, which I don't think will be a problem. And we will hold public comment to the very end. First, I'll bring up the meeting minutes from January 17th, 2023. Is there a motion to approve those minutes? So moved. Second. All in favor say aye. Aye. Aye. Aye. Member Walsh, I didn't hear you. So I'm not sure. Tom, did you vote? Not sure if you can hear me. Hey, Tom, shake your hand if you can see me or hear me. All right, well, we have three votes. So the minutes are approved and I'll check in with member Walsh to make sure he can hear everything. We'll turn to our first presentation, which is a standard qualified health plan design proposal. And I'll turn to the Vermont Department of Health Access. Yes. Hi, this is Dana Hulland, play management director for in Diva. I will just start us off. I'm joined by Addie Stremelow, who will provide some introductory comments at the very beginning. Then we're also joined by Darren Johnson and Julie Pepper of Wakely Consulting. We'll look at us through the presentation after some introductory slides that I will cover. So. Addie, hand it to you first. Thank you. Thanks, Dana. Hello, board members. Thank you for having us today. My name is Addie Stremelow. I am currently the acting commissioner of the Department of Vermont Health Access. My usual job is deputy commissioner of Diva, where I oversee eligibility and enrollment, including the health insurance marketplace. And I just wanted to be here briefly to recognize what an important milestone this is and the kind of annual dialogue around qualified health plans. The work around the 2025 design has been going on now for a few months, but this is kind of the first, you know, public discussion of that topic and an important part of our regulatory partnership. Thank you again for having us. I wanted to mention that in the eligibility and enrollment space at Diva, we have been very focused over the last year on Medicaid and Medicaid renewals in particular coming out of the public health emergency. The restart of that process, which happened last April, has resulted in coverage loss and coverage transitions as expected as people come off of Medicaid and look for other options. What that has, a result of that has been a significant increase in our qualified health plan enrollment, which you'll see in our enrollment data. We are about halfway through a little over halfway through now this this big renewal restart and our overall renewal rate is 60%. But among those who are no longer eligible for Medicaid, we're seeing about a 20 to 30%. What we call conversion rate over to qualified health plan coverage on a monthly basis, which is pretty high, at least in the national conversation. And that does mean that our overall enrollment is higher than it's been in some time. You'll see, I think it's about a 16% increase here over year. There's been a lot of national news around qualified health plan enrollments. I think the sign up succeeded 21 million for this year's open enrollment period. And 5 million of those are from state-based exchanges like Vermont's. Here in Vermont, we had over 30,000 plan selections for 2024, which is the highest we've seen since switching to allowing for direct enrollment back in, I think it was 2016. So hopefully the enrollment enrollment information and kind of landscape distribution of plan selection is informative as you all review the proposed plan designs for 2025. And with that, I will turn it back to Dana to start that discussion. Thanks, Addy. So let me attempt to share my screen. Can everyone see that? Yes. Okay, thank you. So just basically our agenda for the day is to, I will begin by providing fairly high level overview of our stakeholder process and what goes into building the proposal that we have for you today. We'll go through that proposal with our partners from weekly consulting. We provide actuarial services for us. And then as usual, we will be available for comments, questions, discussion at the end of today's meeting and planning to return next week for follow up questions, comments, et cetera. And if prepared for the board's vote. Again, just for review. We are here today to talk about the standard qualified health plans, which will be seven. Plans from each issuer. That's one platinum, one gold. Two silver, one of which is a deductible plan and one is a high deductible health plans in that structure. And then there are three bronze plans to our deductible plans and one is a high deductible health plan. I provided a separate one page handout for your reference. It shows what is available on the exchange in 2024. So that's just for your reference. And we expect 2025 to be very similar. So again, a word about our stakeholder group conversation. I lead this group and we begin to meet in late to late November, early December. Our membership includes myself from diva representatives from each issuer. We have representatives from the healthcare advocates office and then staff from both the department of financial regulation and green mountain care board. So we have very robust discussion and what we do is take. We start by reviewing federal guidance changes as much as we have at the beginning of our process and throughout. So we're discussing a learning level at a time and discuss a good detail to come up with our proposed changes. And then moving on. Again, I won't read these, but. Value affordability stability attractiveness and usefulness or very much on our minds as we go through the. maybe require plan by plan and how to make decisions about cost share benefit changes that will be compliant with the guidance and also attractive at our marketplace for our membership. Let me skip this one. It's a little bit more on affordability. Again, as most of you have seen from previous years, the general idea is that the higher the actuarial value, generally the higher the premium will be. That's certainly true metal level by metal level. So at each plan level, we're very mindful of a change that will affect AV thinking about the likely impact on premium at the silver level. This has the added impact of the higher the benchmark plan, which is the second lowest cost silver plan, the higher the premium for that plan, whichever one it ends up being, whichever silver plan that leads to an increase in the APTC calculation for that year. So that's important. We're very mindful of that as we make any changes in the silver plans. The state supports what can be done to maximize AV in the silver plans to increase that subsidy availability, understanding that not all silver plan enrollees are enrolled through the exchange and APTC eligible. But that's very much on our minds as we make our decisions. The compliant AV to minimize ranges, meaning the acceptable AV range for silver plans is compressed to facilitate the principle of going towards the higher end of AV to maximize APTC. For example, some plans may have that like the goal plan could be minus two and plus two of the 80% average for a goal plan, but a silver plan is only allows the AV range to be 70 plus. And then just to note that the silver loading will continue in 2025 with the functioning the same as it has in previous years. So our approach as we look at each metal level is to do strategic minimal increases. That's to avoid large swings and of an impact from if we do nothing in one year thinking ahead to the next two or three years for large increases or changes may be required, which could be disruptive to the market. We think about the overall cost, which is not only premium, but the cost share decisions that we make, which impact the out of pocket for our enrollees. And then we're very mindful not to create any kind of a plan design or make a decision that could be difficult for consumers to understand. We want their plan information to be as friendly as possible. So then just a quick look at a review of our certification timeline each year. So we are in the process of the first bullet here going through the presentation of standard plan designs completed in by February. And then in March, the issuers will submit their forms, which is summaries of benefits and cost shares and their certificates to DFR with approval anticipated in June. The final notice of benefit and payment parameters is due in the spring each year. That may or may not impact some of the information that we have gone forward with in today's presentation and Darren will highlight some of those things. Rate proposals are submitted in May with all of the process that you're well aware of and final decisions in early August. Then plan certification follows that at the very end of August. That's the step of formal approval and selection for the plans that will be offered on the exchange in the coming year. And then as you know, open enrollment begins November 1st of this year through January 15th of 2025. So that's our cycle. So any questions on our stakeholder process, guiding principles and those kinds of things? Okay, hearing none, I will turn it to Darren. Buddy able to see a PowerPoint and hear me talking. Perfect. Okay, so outline of what we're gonna go over today. This is very similar to previous years for all of you who have been around. We'll start off as Dana mentioned with the proposed regulation changes, especially focused on the out-of-pocket max changes. And then we'll discuss some pretty major differences in the federal AV calculator this year that had large impacts on plan designs. And then go through by plan, what are recommended plan design changes are by metal level. So first off, what are the key regulatory changes this year when we're looking at 2025 related to 2024? So the big headliner off the top is that the annual limitation on cost sharing was released. That's a separate letter from the NBPP. It is finalized. It will be $9,200 for 2025, which is a decrease from the 9,450 in 2024. So this is the first time that has decreased. So that'll have some impacts down the line on how we did some of our modeling, but that's a keynote up front. That 9,200 is the highest. We can set the individual out-of-pocket maximum at. And then we mentioned kind of those federal HDHP minimum deductible and out-of-pocket maximum limits. So what's the smallest deductible we can have and still have a plan qualify as an HDHP in 2024? These were 1,600 and 8,050 respectively. We usually expect that to increase 50 bucks every two or three years. It's been increasing more recently due to inflation. Our best guess right now is that'll go up to 1,650 and we'll have to tweak plan designs a little bit and I'll point those out when we get there. But we'll kind of see once we get that estimate. That out-of-pocket max limit increased by 550 last year, that doesn't have as large of an impact on plan designs. Typically it's more the deductible one we have to worry about and we'll kind of see where that goes this year, especially with the decrease to the individual limit. For now our proposed plan designs are just assuming that that deductible limit will remain at 1,600. Assuming it does change, we'll have to adjust some plan designs, but typically those are fairly minor adjustments. There were other changes in the 2025 notice of benefit and payment parameters. There was nothing major, nothing that really impacted plan designs directly. If anything changes in the final one, obviously we'll address that at that time. So the draft actuarial value calculator. So this slide just kind of describes how the actuarial value calculator works. This is a model released by CMS that determines in actuarial value what percentage of total health costs are paid by the plan for the purposes of determining compliance with metal level requirements. Notably this is not a pricing AV. It's based on summarized national data. It's not based on Vermont specific experience. It uses kind of national level trend factors. Each carrier will have their own model and the methodology may differ. And not all service categories are represented in the AVC. So notably they don't have an input for like urgent care. So if you have a different copay for urgent care, that's not something they really capture. So what changed this year? So first off, reminder that it's currently in draft format. Typically we don't see changes between draft and final, but it is always possible that they could change something between draft and final and we'd have to go back and remodel and make sure that everything was still in compliance. So the big change this year was they updated the data underlying the model. So for a number of years, they'd been using a data set of 2018, primarily large group data, but group data. They updated the data set to 2021 edge data, which is a name for where they collect ACA data to run like risk adjustment and high cost risk pooling calculations. So it's 2021 ACA data, both individual and small group. They trend it from 21 to 25. The most recent year of trend was a little higher than usual again, kind of due to the general, no inflationary environment. And then they lowered the ceiling at which they threw out members for outliers. And all of these together meant that Silver and Bronze allowed costs actually decreased by a decent amount, almost 4% compared to 2024, even with an additional year of trend. And the impact of that is that the lower a population's PMPM, the lower the AB will be on a given plan design. If you have a $2,000 deductible and your population accrues $10,000 of costs a year, that deductible is a lot more valuable than if your population accrues $4,000 of costs a year. So any decrease in the loud cost decreases AV. The impact of this is it actually reduces the magnitude of changes required. In normal years, most plans are near the top of the AV de minimis range. The AV updates, they kick out above the top, we have to lower benefits to get them back within those required ranges. This year that is still the case somewhat for some plan designs, but especially Silver and Bronze, it's generally the other direction where AVs actually decreased year over year. There were some other changes about how costs shifted between categories. I highlighted a PCB versus specialists actually on the drug side, I think was where we felt the impact a little more with a lot more drug shifting to specialist and non-preferred brand. But overall kind of this change in a loud cost was probably the biggest headline. As we go into the plan design slides, after this, we're gonna be talking about estimated premium impact, we're gonna be showing on slides. In the past, we've just had this as kind of a percentage based on a pricing AV change in our own internal weekly plan valuation model based on the Vermont specific plan designs. We've added a dollar amount estimate and this was just for the Silver deductible plan, we took the average of the Silver deductible standard, Silver deductible plan premiums in the 2024 market. Just 50-50 between the two carriers, we did not adjust for trend, we did not adjust for contracting or any of the other hard things that go into pricing, just what's the premium last year, if we think the pricing AV will increase 2%, increase the premium 2% and then show that as a dollar value just to make it a little easier to kind of understand the changes that are occurring and all of those are gonna be the dollar value for an individual contract, not for a family contractor, spouse contract or anything. So let me pause there quick, were there any questions on all my information dense slides on kind of regulatory changes? I don't think so. Perfect. So overall, what is the impact of all this? So changes are required to a number of plans due to the federal out-of-pocket max decrease. We had three plans that had out-of-pocket max is higher than that 9,200, so we have to bring it down to the 9,200 just to comply with that. Even if changes are not required, we still had some changes that we thought would be a good idea to avoid either AV increases being passed on as premium increases or just stabilizing changes for further years. And we had to make some changes to the Silver CSR plan designs. Those have a much narrower, de minimis range, so it's a lot easier to fall in or out of that. We do not go through those in this call, but those are included in the appendix if you wanted to review them. And then we'll show the target range we're shooting for in each plan when we get to those slides, but we do have a number of differences between the Vermont kind of standard plan ranges and the strict federal ranges where because the deductible is waived for preventive prescription drugs, we add a 0.5% cushion on the high end to high deductible health plans for the provision around limiting out-of-pocket expenses for insulin. We add a 0.1% cushion on the high end for bronze plans. And then since the AVC does not allow you to model free mental health and substance abuse visits, we add a small multiplicative factor on silver deductible and bronze deductible without pharmacy limit plans to capture those three visits and model that since the AVC does not. So at a high level, what are we looking like? So on this table, I've got the final 2024 federal AVC for the standard plans. Then when we take the exact plan from 2024 and run it on 2025, how did things change? So noticeably for the four of them that actually have a value, they actually all platinum went up a tiny bit and the other three all decreased between a little bit on gold to half a percent on silver and almost 1% on bronze. So pretty noticeable decreases there. And then we had three that we could no longer run because their move was greater than the 9,200 and thus it wouldn't run without adjustment. I believe if the only change we made was just to reset the move to 9,200 these all were still within the ranges. I think the silver was very close to dropping out of the bottom end of the range. And then this is where those features I just mentioned those plan design features. So on silver, we have a 0.5% cushion on the high end for the HDHP on the bronze. We have both the 0.5% and a 0.1% on the HDHP. The non-HDHP bronzes have a 0.1% and then all of these are reflecting not all of these. Sorry, the silver and bronze plans are reflecting that 1.001 factor. So we'll show a number of changes here. The ones that actually require formal approval are as follows COPE-CONTRANCE deductible increases. And then the big one this year is that out-of-pocket max increase. In typical years, this has been if we increase the out-of-pocket max by more than the federal increase it requires approval. In this case, since the federal increase was a decrease even if we leave the out-of-pocket max the same compared to last year it technically will require formal approval because the change is less than the decrease was. So we'll try to show this formatting anything we change from prior plan designs will be shaded orange. Any changes that require this formal approval will be shaded green. And then if it didn't actually change but requires formal approval it'll be green and not bold. And I'll point that out as we get to those. So the high level this is the summary of what has changed. So the only notes that require formal approval are going to be those green boxes where the out-of-pocket maxes were changed and then we have a couple of spots where we've actually been able to decrease benefits or we've decreased co-pays which increases benefits which we'll highlight as we get there in co-insurance as well which really was driven by the ABC changes giving us a lot more room to maneuver than we've had in the past. But we'll get into the specific plan designs go through all of these and then we'll see this slide again at the end. So we'll start off with platinum. So first off I have kind of a history slide of what's changed in this plan over the years. For the most part it's just been small deductible or moop changes every year a little bit of a gap every year again and then a switch to having three free visits back in 2023. So for this plan design we have kind of a preferred in a backup option we're showing. So the preferred option is just small increases to the out-of-pocket max on the medical and pharmacy side just to bring it up to that $1,600 limit from last year kind of true that up between plans a little more and that would have a premium impact of about 0.2%. So this is kind of the first time we're seeing these new premium impact slides so that translates into roughly $2.50 per member per month $30 per member per year and then our backup option was just leave everything the same that roughly doubles the premium impact you see about $4.70 per member per month again just from impacts to plan design not from any other pricing impacts but those were kind of our thoughts on the platinum plan. And then yeah we're keeping the deductible consistent that's changed a lot in recent years like to just leave it flat and then increase the pharmacy out-of-pocket max to be consistent with kind of the HTHP levels bring medical to the same level. On the gold deductible plan this is one that typically we hit the far end of the range and have to cut benefits a decent amount to bring it back in. We can see in 2023 we had a $200 increase to deductible and move in 2024 we decided to give consumers a break on that side and just increase co-pays instead. And then this year we have again kind of two options so the preferred option for this one is actually leave everything the same except for taking the pharmacy out-of-pocket max up to $1,600 again the HTHP limit I've talked about. So this is again this technically requires formal approval because we're not dropping the MOOP 250 but we'd be leaving the MOOP the same. That is a higher premium impact than the platinum plan does. We'd be looking at about a $10 PMPM premium increase from leaving benefits the same while costs are presumed increasing. So these benefits would be worth more this year at predicted cost levels than they would have been last year just due to trend and benefit leveraging. So we did include a backup option as well which would be just a small increase to the medical out-of-pocket max just to take a little bit out of that, that premium increase but the preferred option was leave the medical out-of-pocket max the same and just increase the pharmacy one a little bit. So again, give consumers a break on the large deductible and MOOP increases not touch co-pays and then increase that pharmacy out-of-pocket max to be consistent. Silver deductible plan, so this is another one that traditionally has needed large increases year over year to stay within the de minimis range. The silver range is only 70 to 72% so fairly narrow compared to gold, platinum and bronze which all have much wider ranges. So you can see 2023 $600 deductible increase, $550 maximum out-of-pocket increase. 2024 we got a bit of a break. Last year they had some methodology changes in the draft AV calculator that made co-pay plans look less rich in terms of what the calculator was calculating which helped out a little bit. So last year we only had to increase the MOOP a little bit. We didn't have to touch the deductible. We didn't have to touch co-pays. So certainly an improvement compared to 2023 in terms of changes needed. So this year this is a plan that after the changes as I mentioned was on the very low end of the de minimis. And generally as Dana was talking about the silver plans we try to aim to have a little higher on the AV range to maximize the second lowest cost silver plan, maximize your APTCs for all consumers. Obviously we only control the standardized silvers but generally if these are moving up presumably other ones in the market might move up as well. So the second lowest cost silver plan should move similarly to these. The dynamics should be the same around silvers. So the preferred option here is actually a lot of benefit increases for the first time ever. So the medical deductible cut by $500 to $3,500 the MOOP we bring down to that federal limit. So again this requires approval even though it's a MOOP decrease because it's not cut by $250. We would increase the pharmacy MOOP still to that $1,600 threshold and then give back an ER copay increase from a few years ago. I think that was 2023 as well. And then cut the generic drug copay also back to that pre-2023 level was the thought. So the trade-off here for all these increases we end up kind of smack dab in the middle of the AV range. So this one target in the top can go 70 to 72%. We're at a 71% right in the middle. There is a pretty substantive premium increase associated with all of those. We project roughly 2.2%, $250 per year for an individual contract, $20 a month for an individual contract. The hope is that for subsidized members most of that flows through into subsidies and is not realized but obviously for unsubsidized members there's a trade-off there with these benefit increases. So we did include a backup option that cuts that at least a little bit. So this one is the same except the deductible decreases by 250 instead of 500. A key thing to note for this plan too is I kind of skip over these rows a decent amount of the time but they're very important for understanding the dynamics of how responsive a plan is to what the deductible changes are. So for this plan the deductible is waived for lots of things, all preventive services, all office visits, urgent care, ambulance and then all generic drugs. So changing the deductible does not have as much impact as the overall AV as it would in some other plans where the deductible applies to more things. And I'll highlight those when we get to that. So that's why this $250 deductible increase which I think sounds pretty large only really knocks premiums down about a dollar per member per month. But that's what we're looking for on the silver deductible side. And I've talked to most of these but we have it in the slide as well. Just trying to use the space we've been given to kind of undo some large increases in recent years and hopefully encourage medication adherence by cutting the generic drug copay a little bit. We could slash that ER copay in half without a whole lot of added cost sharing burden, added premium burden and then lower cost sharing burden when emergency care is truly needed. And then as discussed, theoretically we could take this up to 72% but that would result in a much higher premium for non subsidized members. And then next year presumably we're going to end our train of luck of methodology changes and data changes being the large changes in the ABC versus just trend and get back to a spot where silver ABs increase one to one and a half or even higher percent year over year and if we're at the very top of the limit then next year we're just gonna have to yo-yo back on these benefits. Whereas this way, hopefully there's a chance where this plan can stay mostly the same next year and still be compliant with the federal limits. Next up is the silver HDHP. So this slide's a little messier with all the changes to the embedded MOOP having to be highlighted. But last year we decided to increase co-insurances instead of touching the deductible just to give a break from kind of the big deductible increase in 2023 and deductible increases for several years before that. So that was the major change last year was on the co-insurance side. So this plan is gonna be pretty similar to the silver deductible in terms of where we ended on the AV range and right around a 71%. Our preferred option is basically leave the deductible and MOOP the same. The embedded deductible decreases with the federal decrease and then give a little bit back of co-insurance on the PCP and mental health and substance abuse office visit side. Hopefully encourage more of those types of visits. And this plan may have to change a little bit should the HDHP minimum deductible shift that would be this pharmacy out-of-pocket max here would potentially have to go up to 1650. We wouldn't have to change anything else about the plan if that would happen. It would still definitely fall within the de minimis ranges. As a reminder, this plan, the ceiling of the range is 71.5%, not 72% due to being an HDHP and the Vermont specific provisions for HDHPs around preventive drugs. So we're closer to the top of the range than we were on the silver deductible. And the estimated premium impact of all this is about 1.4%, $13 per member per month, 160 per year. Backup option is just leave the co-insurance the same, cut that premium impact just a little bit, about 50 cents per member per month. So the preferred was to give that co-insurance back but did include the backup option as well. And again, talked about all these, the co-insurance doesn't have a huge impact on premium but hopefully encourages some more preventive and appropriate use of services for members who are impacted. And again, similar to the previous one, we're not maximizing the AV just to kind of at least cut that premium increase a little bit for non-subsidized members and give us some breathing room going into next year. Next up onto the bronze plan. So this is the bronze deductible plan with the pharmacy limit. This one has not had as many changes. In general year over year, the bronze plans have a much wider de minimis range. So unlike silver and gold, we're not always at the top of the range and having to make big changes just to be compliant. So 2023, well, everything else was getting huge benefit slashes. This one had a out-of-pocket increase, somewhat substantive, but not as changes across the board. Last year again, we brought the out-of-pocket max up to the federal level and then had an increase on the generic drug copay. So changes for this year. So the preferred option is we bring the out-of-pocket max back to the federal maximum level, which would be a decrease in that and then take the pharmacy out-of-pocket max up to that HTHP limit to align with the other bronze plan and then give that copay increase back that we had just last year, go back to the $15. And that has a decent premium impact, 2.5%, $215 a year, $18 a month. Bronze members are often going to be more premium sensitive. So that's definitely something we discussed was having that level of premium impact. Again, hopefully a lot of these members will be subsidized and if silver plans are increasing a similar amount, hopefully APTC subsidies are increasing to help deal with that premium impact but did want to note that. And then the backup option would just believe the generic copay the same and it tweaks premium impact a little bit. And then tie the ABC range there for bronze plans. For this plan, it's 58 to 64.9%. So we have a very wide range. We're kind of in the middle upper end of that range. So it's rare that we would get over that 64.9%. And again, reduce the generic drug copay and encourage medication adherence, hopefully. And then as discussed, we're trying to balance stabilizing the cost share increases or even giving back a little bit cost share decreasing and then anticipate a premium impact for these members who are likely more price sensitive. On the bronze deductible side, so this one does not have that pharmacy limit. And this plan is very simple. The deductibles only waived for preventive and office visits and then generic drugs. And then the plan basically just increases to match the federal deductible and move or be very close to it year over year. So this one, the primary option is pretty simple. Just cut deductible and move back down to the new federal limits and then give a little bit of copay back on the generic side. The backup option is cut things down a little bit more and have the same copay reduction. So preferred option $200 for member per year premium increase. The backup option is a little more expensive on the premium impact side, but not too much higher. And then yeah, again, similar to the other ones, reduce the generic drug copay and courage adherence, bring that out of pocket max and deductible down to the new federal level. And again, we're balancing these priorities on the bronze plans. And lastly, we have our bronze HGHP. So this one has been fairly small deductible changes year over year. Some updates to the move to match to those federal limits as those have changed. And then this is just the deductible is waived for basically nothing. So this is a big contrast to that silver plan we were looking at earlier. For this plan, the deductible applies to everything other than preventive categories and preventive medical categories and preventive scripts. Everything else has the deductible apply. So for this one, the preferred option is cut the medical out of pocket a little bit, bring that down to 7100 and then just the embedded move resets to the federal limit. That's about a 1.7% premium impact, about $150. So not as high as some of the other bronze plans, assuming that this is probably the most price and sensitive members looking at this HGHP bronze plan. And then the backup option would be, let's cut that premium impact even more. We'll increase the deductible a little bit. We'll take that premium impact down to about $135 a year, just from these changes to the plan design. And again, this is the other HGHP. So if this, the minimum deductible changes, we might have to increase the pharmacy deductible and out of pocket maxed a little bit to align with that. So that it is still in HSA qualified plan. And yeah, small reduction, cut member cost sharing a little bit. And again, with the bronze plan is just balancing those priorities. So now back to the summary of everything. So I apologize for that. I went through everything quickly. Were there any questions or specific plan designs you wanted to go back to and kind of look at it in more detail or anything I've discussed that would be helpful to cover again? Yeah, thank you. Very quickly, could you go back to the slides? They show the premiums, I say not the premiums, but each of the plans. There's a lot of information on there. And I was just getting oriented to what is where. So... This one there. Could you bring up 18? 18. Nope, 19. This one, but for each of the plans, okay. I'm just looking at the estimated premium impact per year and per month. And I didn't see that at first because I was looking at the green and the pink. So could you just show that for gold, silver, and bronze? Also, please. Yeah, so for platinum, I'll just quote the yearly numbers, basically 30 and 60 for preferred and backup. And I apologize for not bringing more attention to that the first time. For gold, much higher, about 110 for our preferred and then 95 on the backup. Silver deductible, this is, I think, the most impacted one. We have 250 for the preferred, 230 on the backup. Silver HDHP, 160 on the preferred, 155 on the backup. Bronze deductible, 215. You got the other, Bronson. Thank you. And again, stressing one more time, this is just due to plan design changes and the impact of trend on benefit leveraging. We're not accounting for the impact of trend on medical costs or any other considerations for premium impacts. We're set another way. It's important that we not try to draw a straight line from the figures that we're presenting here based on the benefit calculator and our plan design decisions on compared to what will come from the issuers in their pricing model and plan by plan, premium increases. So this is just a directional comparison year over year trying to assign some dollar value to it, but it's not fair to say that that will be the premium increase for any one of these plans. I know that's hard. Thank you for clarifying. And Darin, just a moment ago, you said something about used medical trend twice. And I had as a question to ask later, what is in your analysis, what's the largest driver of these increases year over year? Yeah, so medical trend, that's a good call out. There's the impact on just medical costs. So if costs are $800, there's 5% medical trend. Now they're $840. There's an additional $40 of cost. That's one, we don't touch that. What we do touch though is the impact of trend on benefit leveraging. So when I go and model these plans to get these premium impacts, the 2024 plan, I model at a 2024 PMPM level based on assumptions we've worked through with the state. And then the 2025 plans, I model at a trended amount. So we assume a level of trend and model at that higher PMPM. So because of that, the same deductible in 24 and 25 are worth different amounts. The 25 one is worth more because we assume higher costs, more members hit their deductible, more members go over there out of pocket max. That same benefit is worth more. So this year, the majority, it depends on the plan. Cause some of them we made pretty substantive benefit decreases on. So like the silver deductible, we had a lot of benefit increases. So a decent chunk of that is going to be just the benefit increases. But I think even on this plan, the majority of it is that benefit leveraging. If we are modeling claims increasing 7% a year, 6, 7% a year, these plans are impacted more. On the platinum side, where we had that much smaller premium impact, the allowed claims level for platinum members is a lot higher than it is for a bronze member silver member. So the additional trend matters a lot less. Like most of these people are so far over this deductible and moop level that it just doesn't, doesn't matter as much as claims increase where, and these deductibles and moops are so low to start with, where something like your silver plan that has a very high moop, you know, moop near the federal maximum, you know, a deductible that's much higher than the platinum one. There's a lot more of that leveraging impact that happens. That's why we see kind of the much higher, higher premium increase is just due to that component. And thank you, this is all really helpful. It's a complicated thing to follow. When you're talking about medical trend leveraging, what went through my mind is that that seems to be an estimation about how many beneficiaries are likely to go over their deductible and moop, which is then just a cost to the payer, right? And so either medical trend on its own or medical trend leveraging, the driver of medical trend are the prices that are charged to patients, right? So there'll be a price component and there'll be a utilization component. And it'll differ year by year and plan by plan, what those exactly are, but I would say usually more than half is on the price side. I think it's fair to say typically. All right, you answered my next question is can you divide out the price versus utilization? So over half of the medical trend change year to year is driven in your estimate by rising prices. Okay, thank you very much. That helps a lot. And thanks for looking back at the tables with me. That's a quick question while this table is up perhaps. In terms of, I'm looking at the ER copay, co-insurance column and the drop from 500 down to 250. I'm just wondering if you could talk a little bit about the logic behind that. When we think about trying to deter avoidable ED visits and encourage more PCP visits. So is there any thought to perhaps increasing the number of visits? Sorry, now it's gone, but the number of free visits for primary care, but keeping the ER deductible high. And I also was curious about on the same page the pharmacy generic dropping it from 20 to 15 to encourage more generic use or alternatively kicking up the non-generic copay. The sticks versus carrots. So I'm just sort of curious the logic behind some of that. Yeah, so on the ER side, a key thing to note here is that the medical deductible is not waived for ER admissions. So if you're below your deductible and go to the ER, the whole cost goes to your deductible. So it's gonna be a very, fairly expensive claim. I've got several toddlers, we've had some ER claims for various things over the years, so I have more knowledge than I would prefer to of ER costs. So that if you're under the deductible, you're still seeing that whole claim. It's only gonna be people between the deductible and the out-of-pocket max who even see that copay. And at that point, there's a question between discouraging and just high cost sharing, $500 is a high copay for any ER visit. That's close to the, I'd say 50% coinsurance for at least a lot of ER visits for asthma and EpiPens and the like. And then slashing this, you're not gonna impact that many visits because most people will either be under the deductible or over the moop. And again, it's only those visits that take place in between that are hit. And then we had just increased to that level back in 23, which was kind of part of the suite of changes needed just to get the plan compliant. So at that point, I don't know that it was a very, we want to decrease these visits, so we're gonna double this copay as much as this plan has to be compliant. What can we do with as little, hopefully impact on behavior is a needed medical behavior that we can make to just get this plan compliant. So reversing it seemed like a reasonable approach to take. It doesn't have a whole lot of premium impact again because there's only gonna be a small portion of visits kind of in that window. So it's kind of the thought behind that. On the generic side again, it was pretty similar logic where this was just increased back in 2023 again. You know, the brand copay was increased at the same time. We left that one the same. So relative to where they've been in the past, there's more difference now between those two. It used to be a $45 difference. It increased to 50. Now we've increased it to 55. And on the office visit side, it was 2023 again where we switched to those three free visits. We didn't have any explicit discussions about, excuse me, sorry, about changing that, the number of free visits as an alternative. You know, this was a plan where we were again, kind of wary of premium impact at least a little bit. So that's kind of where we ended up there. I don't know if that's hopefully, that's helpful. Yeah, no, thank you. I appreciate it. I think there's so much here we all have to dig in, but as my colleague Tom was talking, I was staring a little bit more in detail at this and just thinking about some of those trade-offs and wondered what the motivation might have been. So I appreciate it, thank you. Yeah, and this year was definitely different in that. We actually could explore those trade-offs a bit on some of these plans, as opposed to a lot of years where it's just, how do we get compliant? So it was definitely a different environment. And as Darren said, I think we found it attractive to be able to take two benefits and bring them back to the level from prior years and to be able to market it that way. Stakeholders felt that that could be an attractive change. And also with the drug co-payage and Eric level, many of those drugs come in at less than a $15 price to begin with. So the thought was that that still wouldn't go through to the enrolling, but it would be an attractive change to see. Any other questions? And I'll set, thank you. Perfect. Dana, do I go back to you now? We have nothing additional to present. I think we'll leave it to the board. Great. We're gonna hold public comment in the event there is any. Are you, actually, are you folks leaving after this? Are you staying? You should probably leave, actually. I mean, you don't have to be welcome to stay. I believe we were planning on leaving once we finish this portion. Yeah, yeah. Yeah. So what do I actually do next week? Laura, go ahead. Hi, with Susan not here, I'll point out that there is a, we'll accept public comment on these proposed 2025 standard qualified health plan designs until the end of the day on February 6th, 2024. And people can comment by visiting our website and clicking on the public comment option or by emailing us at gmcb.board at vermont.gov. So Laura, I have not contemplated a stand in for Susan, but now I know where to go if I need one. That was well done. I don't know. All right, well, I'll take public comment now. So if anyone has public comment, please use the raise your hand function. Sharon, hey, how are you? Please go ahead. Hi, I'm just getting back. So I was just thinking about this, how it might be helpful to the board to have measures that I think would be pretty easy for the commercial payers to provide, maybe even other providers. But in the total healthcare expenditures of a commercial payer, we understand that the costs are from direct care and then the cost of an insurer to provide the insurance, which you can name admin or whatever you wanna call it. But the total of what the insurer pays to the direct care. And I understand in the direct care of a provider, there's also admin, but we're just gonna say, what does the insurance company pay for this care? And then also collect what it is that the consumer pays. So the consumer's payments would be the premiums, the deductibles payments, the payments that go to deductibles, the co-pays, the coinsurance. And I would even include subsidies, because frankly, that's taxpayers' consumer of healthcare. But if it's complicated, it's not as necessary. But I am thinking if you track these sort of numbers, if you can reduce this complicated expenditures of healthcare, and this is what the insurance company has paid, and they already give you that number. But what's lacking is how much have Vermonters actually contributed to healthcare costs? Because it struck me just with the deductible of $1,600, that's a lot of money. And I'm thinking, and certainly in my case, what I contributed to healthcare, I never received any benefits being a healthy person. And so that's an expenditure, right? I'm paying for healthcare. And that's, I'm not saying that's right or wrong. What I'm saying is it's important for regulators to really get a grip of how much an insurance company that's ensuring Vermonters pays out of their pocket versus what Vermonters are paying out of their pocket. And frankly, I'm just curious. It just struck me how we don't really know that. But an insurance company would know that because they track all of the bills. They just put them in different categories. They'll put them into the deductible, the co-pay, the coinsurance, and then what they pay to the provider. So they can add those up or you can drill down. I mean, certainly you can get into this if you really want to know, okay, how much of the percentage of total healthcare dollars are going into premiums or how much the percentage is going into out-of-pocket costs with co-pay, co-insurance or whatever in pharmaceuticals. But I'm thinking that we don't have that information or do we and I just haven't ever gotten a handle of it. Well, thank you for your comment. There is a basic measure that comes up in rate review every year, medical loss ratio, which gives you the amount of money from the insurance company, their income that goes out towards paying for medical bills, right? So you can see how much of the cost of what they receive is relating to their operations. If memory serves, there's certain standards you want to look for. I believe ours were somewhere in the 90th, 92nd percentile or something like that from my memory. In terms of like categorizing out each bucket of money from consumers, I don't know if I've seen that, but it's a good question. I'm sure of their large amounts. Tom, did you have something to add? So does the board know how much Vermonters pay? Yeah. Sir? Total the amount of people that are enrolled with an insurance company, then total the amount of their premiums, deductible and out-of-pocket expenses. All of that money is pooled. And then when people are sick and need to use it, it comes out of the pool. And a small percentage, usually around 10 to 15% comes out to run the insurance company. But when you ask what proportion of payments are from Vermonters versus from insurance companies, the proportion from Vermonters is 100%. The proportion from the insurance company that is not from a premium, a deductible or an out-of-pocket expense is zero. Insurance companies are not putting their own money into the care of people. We are contributing money with our premiums, out-of-pocket expenses and deductibles. That money is pooled and then used to pay the bills. So the answer to your question is 100%. That's how insurance works. Thanks for explaining. And then I'll just flag that there is the expenditure analysis which has some of this broken out as well, which a member lunch is flagged and she can send to you or one of us will send to you. Any other public comment? Great, okay. We will move on and thank you, Dana and Addie. Next we have Darren and the Wakeley folks. The health resource allocation plan update by Ms. Fielkowski and Ms. Morton. Thank you. Hi, good afternoon. Let me just take a moment to share my screen. Okay, can you see my screen? Yep. So good afternoon. Today I will be providing a health resource allocation plan update. I'm Veronica Fielkowski, the director of data analytics management here at Green Mountain Care Board and my co-presenter will be Micah Morton, a data analyst also at Green Mountain Care Board. So the goal of today's presentation is to provide an update on ATRAP and we will review the following items. So what is ATRAP? But really today's focus will be special topics including gender-affirming care, reproductive care services, both which will be presented by Micah Morton, the workforce data center, which is an update provided by AHS, presented by me, state health improvement plan, an update provided by the Vermont Department of Health, also presented by me, Act 167 talking about the relationship between ATRAP and Act 167 and then a little bit of a roadmap for the future. So 18VSA 9405 requires GMCB to develop and maintain ATRAP. Legislature established ATRAP in 2003 and updated in 2018. The purpose of ATRAP is to identify Vermont's critical health needs, services, resources to inform board's regulatory processes, cost containment, statewide quality of care, health care payment, et cetera for any allocation of health resources in the state. So really ATRAP identifies health care services and gaps in availability or accessibility and considers the underlying health needs across communities in Vermont. This slide is to show that ATRAP is not just one data source, it's a series of dynamic reports, visualizations and other tools designed to convey relevant information. Many entities across the state are conducting work that helps us understand our current resources, needs and gaps. ATRAP includes data from many partners including Green Mountain Care Board, Vermont Department of Health, Baws NSO, DEVA, et cetera. Vermont has a variety of health data resources which measure and evaluate supply, distribution, cost of health care services in Vermont. GMCB stewards two of those health data resources, the hospital discharge data set known as BUDS and then the all payer claims database known as VCURS. However, these two data sources alone cannot answer all of our questions which is why we consider ATRAP very collaborative in this image shows that. ATRAP resources are updated on the GMC website. The website is currently organized by healthcare resources, has a community focus and a number of other public reports. Here's just a few snapshots of some of the information available on the webpage. Special topics. These are the topics we'll be talking about. Once again, reproductive care services, gender affirming care, healthcare workforce data center, state health improvement plan and Act 167. Just before I hand it off to Micah, I wanted just to provide some context of these two topics. 18, VSA 9405, the statute requiring GMCB to host ATRAP and provide some ATRAP details was amended last year to require including these two topics in ATRAP. The amended section says that board, the board shall include reproductive healthcare services and gender affirming healthcare services as those terms defined in one, VSA 150 and these definitions will be provided on the subsequent slide that Micah will show. I'd like to mention that what we can do with our data sets in terms of analysis is quite limited and Micah will review more of this, but as a high level, those include when trying to understand abortion services under the reproductive care service definition. GMC data only allows us to provide hospital abortion services which represents a small amount of services provided in Vermont and then also we can provide the count of abortion service claims and this is because in vCures or our claims database, the provider and patient information related to abortion services are classified as unavailable. So functionally, this means abortion care claims do not have individual providers, organizations or patient demographic details. In terms of for gender affirming care, we run into challenges around small numbers which you'll see within Outline and Micah's presentation. So Micah is going to provide a few interesting findings from her research in these atrap topics. So I'm gonna hand it over to Micah. Hi, I'm excited to present this for you guys. So given how broad some of the definitions for gender affirming care and reproductive care were in the legislature, the scope of this project was pretty wide and because it's so wide, I've chosen to just pick a couple interesting topics and a smattering of findings. Otherwise, we'd be here for a really long time. So first I'll present gender affirming care focusing on medication use and surgeries and then I'll move on to reproductive care where we have some slides on abortion, pregnancy prevention and annual women exams. So gender affirming care, next slide. What is it? Gender affirming care encompasses a range of social, psychological, behavioral and medical interventions designed to support and affirm an individual's gender identities. So gender affirming care can be for both trans or cisgender people, but for the sake of this presentation, I'll be referring only to transgender affirming care. Next slide, please. Wormone replacement therapy for transgender patients is primarily composed of two categories, feminizing hormones and masculinizing hormones. There are puberty blockers, but they're not represented here because they're typically prescribed to people under 18 going through puberty. So estrogen, spherinolactone and progesterone are by far the most common feminizing hormones, but they're not typically the only options but they're the ones that were prescribed like by far the most common. And masculinizing HRT is primarily testosterone. So our last four years has been a significant increase in HRT prescriptions, roughly doubling the number of prescriptions in both categories. Next slide, please. So you see the same increase in gender affirming surgeries with an annual growth rate of 27.8% over the last four years. Those have also doubled in that stretch of time. And gender affirming care can be split in the top and bottom surgeries, with top surgeries being the most common surgery and mastectomies being the most common of those of the top surgeries. And just to note, not all transgender individuals opt elect to have surgery, no want surgery. Next, please. So there were 379 gender affirming surgeries, procedures performed in the last four years that were captured in B-Cures with the states known of those, 136 were performed out of state or approximately one in three. Those going to New Hampshire were mostly going to Dartmouth and roughly 54% of those going to New Hampshire were on Medicaid. So it's perhaps a lack of surgeons that perform gender affirming care surgeries that take Medicaid in Vermont. And the vast majority of surgeries performed in the last four years, like I said, were mastectomies and specifically maximizing top surgery. Nowhere in Vermont does bottom surgeries and only certain types of breast augmentation are done in-state for more specifics or complicated breast augmentation surgeries that's done out of state. Next, please. So as patients establish care at normal levels stabilized, it's expected to see less visits annually and less frequent prescription instances because the care remains the same year after year. But we would expect to see at least more visits in four years. And this continuation of care is important because receipt of gender affirming care, including HRT is associated with 60% lower odds of moderate to severe depression and 73% lower odds of suicidality. And in a national study of transgender patients who just continue gender affirming care, 82.5% cited external factors like social pressure and lack of access. Moving on, next slide, please. Yeah, so moving on to reproductive services. As I mentioned, there is a huge range of accounts as reproductive care. So there's too much to present with reproductive care which covers contraceptives, abortion, preventative screenings, prenatal care, mental health services and more. So I've selected just a few interesting points. Next one. So these numbers are forming the Vermont Vital Statistics Report and based on the adequacy of prenatal care utilization index, the early and comprehensive prenatal care is essential for a healthy pregnancy and birth. 67% of Vermont mothers received what was classified as inadequate care and 2.4% received no care or delayed care until the third trimester. Those numbers are down from 2020 and 45 plus year old mothers had the highest percentage of adequate plus intensive care and 15 to 19 and 40 to 44 years old had the highest percentage in adequate care. Next. So this slide is based on patient origin and abortions per capita. So there were 1,033 abortions in 2021 and we opted to use the Vital Statistics data because as Veronica mentioned, beakers, suppresses and asks information on both patient and provider. So I chose to make this per capita so as to account for the difference in populations in County. There's a broad range of per capita abortion ranging from just under one per 10,000 patients to almost 17 in some counties. Next, please. Clinics were the most frequent providers of abortions by far. Of the 1,033 abortions in 2021, 920 were provided by an abortion clinic. Just under 70% of these abortions were captured in claims and b-cures, which feels like kind of to be expected just based on the percentage that is captured in general in b-cures. Next, please. Overall, abortion is trending down, both in Vermont and nationally. This is usually credited to increased access to preventative measures in education. Next, speaking of preventative measures, there has been a spike in sterilization procedures particularly post-2020. So this includes vasectomies to the ligation and similar procedures. The same increase is also reflected in long-term abortion, like IEDs that implants for daily or short-term pregnancy preventions like oral contraceptives and injectables have a decreased prevalence over the past four years. Next, so well women exams are recommended to work for annually as preventative care. So it could be a good indicator or if you're productive, preventative care is being utilized. Women living in more urban parts of Vermont are roughly 1.48 times more likely to have received a well women exam than those living in rural areas. Next, from our detailed look, we can look at the odds ratios of a woman receiving a well women annual preventative screening exam by county. For this slide, Chittenden is used as a reference category here and of all note, all key values were significant to all of them. And Orange County has the lowest odds of a woman in Orange County being roughly a third as likely as a woman in Chittenden of having completed a well women exam. That's all I have for you for my monologue, but I'll have this written up as a full report with additional information and data visuals in the near future. And I can do take questions. How about we take questions at the end and I'll finalize the presentation. Thank you, Mika. Go ahead. Yeah, so as Mika mentioned, this, these analyses on some of the access and interesting findings will be packaged and part of a trap online. So moving on to our next update. So the healthcare workforce data center and these updates are provided by agency of human services. So the goal of the data center is to support a healthier Vermont where all receive equitable, affordable and quality healthcare. This is a new workforce center developed recently and is under agency of human services. And the mission is to collect, manage and report on health workforce data to health employers, employees current and perspective and policymakers to aid and health workforce development across the state. The agency of human services has executed a contract for consulting on the establishment of the healthcare workforce data center and the work will produce several reports which include a stakeholder analysis report, a reporting and analytics plan and then a five year operations plan that will include a projection of staffing, data and budgetary needs. In addition to collecting, managing and reporting on standard education, supply and demand pipeline data, the data center will also seek to collect data on health equity in the healthcare workforce. By December, 2024, early January, 25, the data center will have completed the necessary research and stakeholder engagement and data governance activities as outlined here in the phased approach on the slide to fully implement a healthcare workforce data center in Vermont in a financially responsible and technologically secure way by utilizing existing infrastructure within the unified health data space which has been presented in the past. This work at the workforce data center will ultimately provide information and data to be able to provide recommendation for resource allocation by identifying workforce gaps. This is how it fits into ATRAP. It will just be another tool and data source for us to utilize. Now an update on the state health assessment and improvement plan provided by the Vermont Department of Health presented by GMCB. So the state health assessment or I'll refer to it as the SHA is done every five years. The last SHA was completed in 2018. So now is a good time to reassess what has changed, what has gotten worse, what's improved in health, especially in the light of COVID. So the SHA is the overview of what we know about health and well-being of Vermonters at a point in time and analysis of quantitative and qualitative data that examine health inequities by race, ethnicity, gender, age, sexual orientation, disability, socioeconomic status and geography. So the SHA is used as the basis for developing the SHIP or the state health improvement plan. I'll refer to it as the SHIP which is the five year plan that includes the goals and improvement strategies that the department and other state and community partners commit to working on to promote health and health equity for all people in Vermont. So kind of to summarize, the SHA is what we know and the SHIP is what we do about it. So centering data collection for the SHA and priority strategies in the SHIP around these populations listed here, they experience the greatest rates of health inequities especially since COVID. So VDH expects to take about two years to develop both the SHA and the SHIP followed by the five year period of implementing the plan and monitoring progress towards meeting the state's goals. VDH is committed to be intentional about following through and tracking progress over time. The big lift happens in these first two years and the work continues even after that. There are two key data collection activities one being the environmental scan. So this establishes a baseline understanding of common health needs experienced by Vermonters, looks for needs by district communities of focus and across the state. It identifies patterns and trends and topics worthy for further exploration and data collection. So they review public data sources providing health data for the entire state and then counties, community groups experiencing the highest rates of health inequities as presented in the previous slide. Some examples of those data sources in their environmental scan included county health rankings, the behavioral risk factor surveillance system, VT211 referrals, household health insurance survey, et cetera. There's many different data sources that they've used. There's also community engagement aspect which includes interviews and focus groups both virtual and in person. Compensation is provided for people's time and expertise with interpretation and translation services and childcare offered to really get as many folks in the room as possible. This is both statewide and in all 12 districts. So far as of January 16th, these are, this is kind of what's been completed. So there's seven data briefs summarizing findings by population and statewide posted on the health department. They're quite nice. I recommend looking at them. They've done 70, it involves 75 plus organizations in their community engagement. 44 focus groups have been completed or scheduled and 26 interviews have been completed or scheduled. Here's just a summary of the completed focus groups and kind of by which county and community they represent. Data will be shared with people who participated in the community engagement process and then the health department will share county level data with hospitals for use in their community health needs assessments as well. And as you can see that, as you can see this initiative is related to ATRAP as it identifies healthcare needs and a plan for action with a focus on people in specific communities. So that's definitely under the ATRAP umbrella. And next I'm going to discuss Act 167 which has a hospital focus and how that fits under the ATRAP umbrella. So Act 167, hospital system transformation and community engagement process. So Act, as I just said, Act 167 has a hospital focus or hospital area focus, concentrating on people who use the hospital in each area. So my goal is really not to speak about what Act 167, what Act 167 is or the purpose of it but rather show that Act 167 work can be considered under that ATRAP umbrella. The process includes both community engagement and data analysis and then these data help understand the current state and also potential recommendations for the future based on gaps and needs of the hospital focus areas learned by the community engagement process. So the outputs from the process are to help hospitals reduce inefficiencies, lower costs, improve population health outcomes, reduce health inequities and increase access to essential services. So there are many different data analyses being conducted for Act 167. These are just a few examples but these all help to understand the gaps in needs and as part of the process will provide recommendations for healthcare resource allocation. Some other work products that I thought I'd mentioned that are either just completed or worked on, being worked on is the Market Share Report which is prepared using the annual statement supplement report or ASSR. The ASSR is required by 8VSA 3561 and this kind of summary report provides insight on earned premiums by commercial payers which kind of provides a slice of the cost data and then hospital service inventory. We are working on an updated one with 2022 data but the one for 2021 was generated from our hospital discharge data and provides information on the number of individuals seeking care by hospital, by procedure, so inpatient and outpatient, a whole slew of different procedures under those and we've heavily used this inventory for Act 167 as well. A little bit about the future that I'd start with just re-summarizing kind of our vision for ATRAP. So ATRAP should capture what is happening in the state in terms of healthcare accessibility, quality and cost and how we wanna allocate our healthcare resources, deliver up-to-date sustainable and dynamic resources that enables more informed health resource allocation decision-making across Vermont using data, focus on the needs of each regulatory process of GMCB, for example, certificate of need and then foster a collaborative process. Here's a snapshot of our 2024 timeline. The intention is really not to see all the details. I know you do not need a squint but we just wanna show that we have many upcoming projects or updates to some of our existing work that either get updated annually or on some recurring basis. And then I think this also shows again that this is a really a collaborative, there's a collaborative nature to ATRAP, the white background, kind of pieces there at the top or mostly what GMCB is doing. Blue is other stakeholders from across different state agencies and different partners and then the peach color are the different inventories that we update or have plans to update, which we work very closely with other agencies to understand. And then just to finalize, ATRAP is an ongoing process and it requires what I like to think of these four components for both like ATRAP as a whole but then also these individual pieces to it. So we have the requirements gathering, engaging stakeholders, collecting the data or analyzing it, reporting and then how do we visualize and package that information to get our point across and then start over. So it's kind of part of that ATRAP framework and needs to be considered as we move forward. So I think now we can turn it over to Cher Foster, thank you. Thank you very much. I'll open up to the other board members. I had just one question, which was, is this Ms. Morton's first presentation to the board or am I missing one from my memory? First one. Great, congratulations and thanks for doing it. You did a really nice job. Yeah. I don't know how to do the like emoji thing people do, but if I did, they would be going. Any board member questions or comments? I just want to say thanks. That's a lot of work. And thanks for doing such a good job summarizing all the different pieces. So appreciated it and it was nice to get an update. Thank you. I have a couple of questions. One is on, I was intrigued by and concerned by the gender affirming care and the potential barriers to access for Medicaid enrollees. So I'm wondering if we might be able to do a deeper dive into that and try and understand that, you know, we're obviously very concerned about access and that seems to be, if that's, you know, if we can learn a little bit more about that, that would be really helpful. And then my second question was about reproductive care. And I wondered if it's possible to break down. It may not be, I understand the barriers with v-cures, but with abortions, is there any way to unpack the proportion that are medication abortions versus surgical abortions, particularly given the Supreme Court case in front of them about the FDA approval of what it's called Mepheprotone. I can't remember if the pepper is, I can't say it, but the abortion pill. So I'm just wondering, I mean, if, you know, that could have some impact. So I'm wondering if we have a way to unpack that. Yes. So in the vital statistics report, They do actually have that those numbers broken down by the non-surgical options, and that was 743 of the 1,033 more non-surgical abortions. Okay. I think it's usually 50-50 in the rest of the country, so we have disproportionately more non-surgical abortions, it seems like. Yeah. Part of it is because most of them here are during under 10 weeks. Okay. My last question actually has to do with, if you could put the timeline back on, thank you so much for that, that was really helpful. The timeline back up for the HRAP, and I'm wondering how we start to think about integrating a lot of this fantastic work that's in here in our hospital budget process. I'm seeing we have got the patient migration analysis, we have overuse analysis, we have market share report, hospital services inventory, all of these are, there's a hospital profiles by hospital. I'm just thinking as we're in the coming weeks, we're going to be talking about our guidance for the next cycle, and I'm just trying to figure out how do we integrate some of this even more so than we have in the past. I don't have an answer for that, I just want to make sure that we're really using this wonderful collection of data and analysis that everybody is doing, and help us inform our decision-making and hospital budget review. I'll just mention, I think some of our goal with the hospital profiles that you mentioned is to take some of this information that we're already producing, like when we're thinking of bi-hospital stratifications, and put it into these profiles so it is to support other regular tour duties, but also the hospital budget as a supplemental data piece, and take some of these bi-hospital analyses and put it into this one place to streamline the amount of information we have. We've already started thinking about that, at least for the bi-hospital viewpoint for now, and maybe that can pave a pathway of how we think about data in the future as well. I wonder if it's, and maybe this is too soon, so this might be too big an ask, and so please tell me that it is if it is. I'm just wondering, I think toward the maybe the third week in February, it looks like we have our first conversation around hospital budget guidance. I'm wondering, is it possible to see by then a template for what those hospital profiles might look like so we have a better sense of some of the data that we're going to see compiled in a profile? I don't have the timeline in front of me. We're working with a contractor to begin those phases of the hospital profiles. What we can provide is the ideas we have of what information we want to add into it. We're approaching it with a phased approach. Phase one will have more utilization metrics in it, because that's readily available data to us that we have. Then as we're thinking about in the future and working closely with Elena to make sure that these data pieces and metrics that will be in those profiles are helpful in that hospital budget process as well. We are definitely collaboratively working on those. That sounds fantastic. Now, I think it might be helpful, it might be helpful for board members to weigh in on what will be helpful to them to see in those hospital profiles as we think about what's so important in our decision-making. Thank you so much. I'm very excited about all this. This work has been going on for years and I really feel like it's coming together to a place where we can really use it and I really appreciate it. Thank you so much. Of course, it's fun to see all the different work happening in different groups that do fit in this umbrella. Yeah. It's all coming together and it's going to be fantastic, so thank you. Thank you. All right. Any public comment? Okay. Well, thank you both very much and have a good afternoon. Is there any old or new business to come before the board and a motion to adjourn? I moved. Second. In all in favor say aye. Aye. Aye. Thank you, everyone. Have a nice day. We're adjourned.