 Good afternoon and welcome to the green mountain care board meeting. And I see all four members of the board on the screen. So we are all set. It's an official quorum and I'd like to begin today's meeting by calling on member Pellum who has asked for a request to change his vote, which would require a request for reconsideration. So member Pellum. Sorry about that. But as we went through yesterday's discussion, I kind of disconnected the fact that our reconsideration vote was not just about the unification of the COVID rate and the standard rate, which I didn't have a problem with. And that's why I voted yes because I thought because I could support that. But in reality, if you go back to the discussion, the reconsideration vote was about the whole, the whole vote and being reminded of that, I would like to change my vote from a yes to a no. And so I'm making that request. So in order to do that, the first motion would be to reconsider the motion at yesterday's board meeting. Can I make that motion? You can. Well, thank you. Well, I would like to move that I be allowed to change my vote on the UVM medical centers vote of yesterday from a yes vote to a no vote. So the proper motion, which I will second is just to bring it up for consideration first. And is there any discussion on that? Hearing none, all board members in favor of taking the vote up for reconsideration signify by saying aye. Aye. Any opposed say nay. And unless there's further discussion, then I will ask a counselor barber to call the roll. Just to be clear, Mr. Chair, this is calling the roll on the same vote. Exactly. Yesterday. Got it. Start with member Pelham. No. Member lunch. Yes. Member Holmes. Member Eastford. Yes. And Mr. Chair. Yes. So I want to thank you folks. Oh, no problem, Tom. I thought that's what you wanted to do, Tom. We were a little bit perplexed. We didn't want to call you up yesterday. I was driving into the store and it dawned on me halfway to the store that I've made a mistake. And then I talked to Michael and he confirmed that I made a mistake. So things happened, but thank you very much. No problem. With that, I'm going to turn it over to the executive directors. Isn't there for the executive directors report? Thank you, Mr. Chair. And I have a couple of announcements. First, our press release for October and our meetings are posted on our website. We have, in addition to our regularly scheduled meetings, we have on October 6th from 2 o'clock to 4 o'clock, our data governance council meeting. So Tom Pelham will join me as the board member. He's a member of that data governance council with others. And that is a public meeting. Please, for those interested, please observe and provide public comment if interested. I also, in follow-up to the meeting yesterday, I will have Mike Barber confirm this. The decisions now, since we are putting them out, we had that final decision yesterday. The decisions will be moved out now and they are due by October 13th, which is exactly two weeks from yesterday. So I wanted to announce that as well. And lastly, there was one more public comment that came in regarding the hospital budgets and that is located on our website for all to see. And the board has been sure that public comment. And that is all I have to report. So just one technical correction since we just re-voted technically, the legal team have one extra day. They may not need it, but that's the interpretation of the... Yeah, for the record, it would be October 14th, Wednesday, October 14th. For the one hospital only. Yeah, perfect. Thank you. Okay. The next item on the agenda are the minutes of September 15th and September 16th. So moved. I'll move approval. It's been moved and seconded to approve the minutes of September 15th and September 16th without any additions, deletions or corrections. Is there any discretion? Hearing none, all those in favor of the motion signify by saying aye. Aye. Those opposed signify by saying nay. Let the record show that the minutes were approved unanimously. The next item on the agenda is the vital quarterly report. And I'm going to turn it over to Beth Anderson and her team. So, Beth, whenever you are ready, if you could just introduce who you have with you. I will do it. Great. Thank you for having us. First, I'd like to start with introducing Maureen Gilbert, who is new to our team. She's probably on camera somewhere. We may probably know from presentations for other topics, but she joined us officially at Vital in August. And she's our new director of client engagement. In addition to Maureen, we also have probably the usual cast of suspects. So Carolyn Stone, our director of operations. Bob Turnow, who is our, I'm sorry, chief financial officer. Christopher Shank, who is our director of IT. And Frank Harris, who is our strategic technology advisor. So today we have our usual quarterly update, but we've got a number of, I think, hopefully interesting topics to kind of keep you updated on. First, Maureen will start and she'll give you a little bit of an update on where we stand with both the kind of change of content policy that happened earlier this year as well as work that the team is doing around planning for beginning to capture hopefully next year sensitive part two data. And she'll talk about some of her outreach and engagement efforts around that. Christopher will present some information about our efforts to make sure that we will be in compliance with the interoperability rules that were announced this spring. Both work we're doing internally to make sure we are, we are kind of in compliance with the rules, but also the work that we will be doing, potentially be doing to help others that will be impacted by these rules. Next, you'll hear a combined presentation from both Carolyn and Bob, giving you an update on the collaborative services project. First, you will, and I will tell you up front, you will hear that there's been a bit of a delay in the implementation date for that project. We've, I think, you know, hit some learning curve with working with both a new vendor and a new relatively leading edge platform that have made us kind of just slow down the project just to do a little more planning. Also, we find that the team is, is our internal team is facing some competing demands of trying to work with the Department of Health and meeting their data needs around COVID and onboarding new providers that have slowed down. I think the important part though that you'll hear is, you know, we remain really excited about the new platform and the capabilities it's going to provide for us and our stakeholders in the future. And I think it still is a really great opportunity. Bob will then talk about in response to a question that came up at our last presentation about some of the projected savings from the collaborative services project as a whole. I would just like to say while the numbers already look good, we expect that this will be kind of a constantly changing and evolving analysis that we will continue to do because as we learn more about the platform and expanded usage, we expect we'll have even more and more benefits. So you'll hear from us about this at future meetings too, likely, unless you ask us to stop telling you about it. And then finally, you'll get just the regular quarterly operational and financial updates. In addition to these efforts, I just want to mention a couple of other things we have going on. Internally, our work with the Department of Health and the Agency of Digital Services continues to help support the state's COVID data needs. Bob, if you don't mind just switching, I think two slides forward. Three slides. I'm sorry I lied. One more. Thank you. Largely, the work has been around helping the state and hospitals to provide the required reporting that they have to do. Last time we talked, it was CDC. Now it's to HHS to make sure that that is happening to both make sure we're in compliance with the federal requirements, but also kind of try to automate the reporting where we can to save some of the manual burden that was put on the hospitals and VDH. We've also been working with a lot of providers who are doing testing, COVID testing across the state to make sure that they are linked in and getting their test results all into VDH as well as the facilities for which they are doing the testing. And we've also been spending, the team has been spending a good amount of time working with the team at VDH to understand what immunization planning is happening and where we will have data needs and data collection needs. So we're ready for that going forward. We're also working with Diva to start talking about our CY 21 contract. Those discussions have just started. Key themes are continuing the implementation of the future data platform, increasing access to the VHI across the state and expanding the data available. And you will likely hear more from us at our next meeting about what the more specific deliverables. And then finally, I just wanted to give a brief update on some organizational changes. After 10 years with us, Dr. Bruce Bullock decided to retire from the vital board this summer. And so the board has elected a new slate of officers, only a full-on from the health network, where UVM Health Network is now our chair. And we've also added three new members who I think bring some great skills. And those are Jeff Teeman, who I think probably needs no introduction to this group. Tim Kenny, who brings extensive IT background and Deborah Rice, who comes with some really strong finance and operational skills that I think will be great additions to our work and our planning going forward. So I'm happy to answer any questions. If there are not, I will hand it over to Maureen. Any questions for Beth? I guess you can hand it over to Maureen. Thank you very much. All right. So just here to give you a little update on the Consent Policy work, both the opt-out consent work that you've heard about already and some planning for incorporating sensitive data into the Vermont Health Information Exchange. So next slide, please, Bob. So this is an update on consent requests since we first started talking to the public about their rights and options around the opt-out consent policy. This is just quantifying it. I think what you can see here is a sort of predictable bump in engagement around the time that we were communicating most publicly in Front Porch Forum, in VPR sponsorship, putting out press releases. More opt-outs at that point. And you can see that sort of the rate of opt-outs to date. And I will say here, just a reminder that with opt-outs, we're not thinking of those as a bad thing, but simply a choice that a small minority of people are apt to make when we are educating effectively about the consent policy. So next slide. All right. So we did pause broad outreach in April, recognizing that it was a time when health-related messages really needed to be focused on COVID and how people could keep their families safe. And this sort of messaging was apt to be drowned out. So we did pause there, but we did do ongoing development of resources to support providers and healthcare organizations in communicating with their patients. So we've been creating some new things there, and I'll show you an example in a second. And we're also working to remind stakeholders of resources that are available to support targeted communication with the populations they serve. Thinking back to that broad outreach, when is the right time to go back out with more public messaging about the opt-out policy? This is a conversation we've been having with our stakeholders recently. I will say there is some different opinions about it. Some folks thinking that really now with everything that's happening in our world is not the time to introduce a message of this sort, and other folks thinking that it might be appropriate to be communicating publicly. So we're sort of assessing that out and seeing where it lands before rebooting any sort of front porch forum or other outreach strategies, broad public outreach strategies. So the next slide is going to be an example of the resources that we're providing for healthcare organizations, providers, and other stakeholders. This is a new flyer on the left. You'll see that we created, we recognize that many folks were moving to telehealth encounters, and they needed more than that printed brochure that we had distributed widely. So we created a PDF two-page flyer that could be distributed, you know, printed on demand for sure, but also posted in provider portals or emailed to patients. And also recognizing that there is a need to make this message accessible to people in Vermont regardless of their preferred language. We did translations into seven languages, and you can see little snippets of that there, including some translations that I think are actually really beautiful. So any questions about that before I move on to talk a little bit about our work to think about how we integrate sensitive data into the health information exchange? Okay, next slide, please, Bob. So this is a really exciting project that we embarked on this year. It is a group effort to think about how we might bring substance use disorder data and other sensitive data into the Vermont Health Information Exchange in a way that helps providers get a more holistic view of their patients and really provide whole person care that is safe and effective, while also respecting the privacy needs of patients, recognizing that some of this data feels different than general medical data to some patients. This started with a focus on meeting the 42 CFR Part 2 data sharing rule. I will say that's rapidly shifting in response to the CARES Act, which introduced a provision that is going to make it so that with a single consent form signed at a Part 2 organization, what we used to call sort of Part 2 data can then be shared on under the rules of HIPAA without the sort of more stringent traditional restrictions on disclosure and redisclosure. So that's something that is expected to take effect March 27th of 2021, something that we're watching really closely. And what it does do is it opens up a conversation for us that helps us really talk to providers and talk to patients about how do you want to share this data, what feels right, what feels appropriate, think a little bit less about sort of traditional restrictions and a little bit more about really what is going to be best for providers and patients. So it's sort of an exciting change that's happening there. In order to explore all of this, we convene the stakeholder advisory group with representation from the designated agencies, the FQHCs and substance use disorder treatment organizations. And we're working together in a couple of phases and the next slide we'll show you those two phases. So Phase 1, this is where we are right now. We are working to design policies and procedures. This is an expectation in our contract with DIVA for the end of this calendar year. In order to get there, we believe it's essential that we have deep stakeholder engagement and are really listening to the organizations and individuals who are going to be impacted by this new policy. So we're doing one-on-ones with interested organizations, focus groups with providers and staff. We just had a great focus group yesterday with clinicians at the Brattle Barrel Retreat, which is really interesting. I'm talking with their staff tomorrow and we'll be doing focus groups with that sort with other organizations as well. And we're also working on engaging patients in this project and really hearing from patients who would be impacted. And then we will design an approach and propose that and get stakeholder feedback and then write it up as policy and procedure for the health information exchange at the end of this calendar year. What that sets us up to do is Phase 2, which is piloting implementation of those policies and procedures. And that's sometime, you know, early-mid calendar year 2021. And it's work that we will need our new Medicsoft platform and a new provider portal in place to support that. We are aiming to engage a designated agency, an FQHC and a specialty treatment setting and piloting, recognizing that things might look a little different in each one of those settings. And really, you know, see how it goes, see how it's working for providers and patients, see if our education strategies are effective and learn from that and then iterate with feedback from provider staff and patients. So any questions about that project? Any questions? I have a different question on that slide if you would Maureen. I'm wondering which of the organizations are you referring to? How did you choose them? And in particular, how did you choose the patients with whom to engage in that outreach effort for stakeholder engagement? So the designated agencies have been with us from the beginning on this project sort of aligns with their new medical record implementation. And we are still working to identify the designated agency that we will pilot with and same with the FQHC. We have gotten commitment from Brattleboro Retreat so they will likely be our specialty treatment setting. So some of this is really willingness to dig in with us and really spend some time designing these policies and procedures. Patience, that is a live question. We are working on figuring out the best way to engage patients in this. We are thinking that some of the recovery networks might be a good way to bring patients in into this. But good questions and ones we're working through right at the moment. Maureen, on the FQHC and the specialty treatment center, you already said that specialty treatment would likely be Brattleboro Retreat. Is it your desire for this to be geographically homogenous or are you looking for geographic diversity? I think geographic diversity would be nice. There are some benefits to engaging multiple organizations in the same geography because we can see how they share data with each other. But I think first it's about willingness to engage and dig in. And second I think geographic diversity would be a plus. Certainly as always we are careful to not just concentrate everything in the Burlington area recognizing that that can be a little different than the rest of the state. Any other questions? I don't believe so. Well thank you. Good afternoon everyone. Recently the Office of the National Coordinator for Health Information Technology and the Centers for Medicare and Medicaid Services have introduced new rules around health information interoperability. So today I'm going to share with you what we at Vital are doing to prepare for these changes. So the ONC rule is part of the 21st Century Cures Act and it's called the Interoperability Information Blocking and the ONC Health IT Certification Program Final Rule. The CMS rule is simply the Interoperability and Patient Access Final Rule. While these two rules have similarities they are two distinct rules with different applicability, different requirements and different deadlines. The CMS rule does however draw on the technical standards set in the ONC rule. The ONC rule is primarily aimed at certified electronic health record technology with a strong focus on information blocking. This rule applies to providers, HIT developers and health information exchanges like the VI. Information blocking is defined as a practice that does or is likely to interfere with the access, exchange or use of electronic health information or EHI. Since the ONC rule clearly applies to the VI here are the implications and what we're doing to prepare. The provisions will be effective as of November 1st of this year but enforcement has been extended to February 1st of 2021 due to the COVID-19 pandemic. Electronic patient access to EHI is required without special effort and as of May 2nd, 2022 certified electronic health record technologies must support the technical standards listed here. To prepare for these new requirements we are building a readiness plan and we will ensure the VI is compliant with the rule. Being built using FHIR standards we plan on leveraging the capabilities of the new MedicaSoft platform to meet the requirements. Additional work includes ensuring all procedures, processes and documentation necessary are in place. We will also have our meaningful use consulting staff build expertise so that they are able to educate providers about how it may affect them. Next slide please. As for the CMS interoperability and patient access final rule this is not directly applied to the VI. However, VITAL may be able to provide a service to others. For instance, Vermont Medicaid program is developing a compliance plan that could involve the VI with its increased data scope. We may also be able to assess hospitals in meeting new electronic event notification requirements by May. We're working with hospitals and BAS to determine interest and potential solutions using ADT events. Are there any questions about these new interoperability rules or are some responses to them? Questions? Yes, I wonder if you could just give a little bit more granularity to the concept of information blocking. You know, if information blocking is an issue that is intentional or is it circumstantial I'm just trying to get something that I can more readily grab to understand that term. Sure. It is a fairly complex rule for sure but ultimately it doesn't matter whether the act is intentional or otherwise and an act can also be an omission. So basically anything that what's considered an actor does or doesn't do that does or has the potential to block interoperability consists of information blocking. And an actor is basically one of the types of organizations to whom it applies. So even if you are not actively trying to information block but you have a system in place that makes interoperability very challenging or even impossible you can still be fined by the rule. So who is the referee when it becomes contentious? ONC. Thank you. Do we have any type of revenue streams these potential services could provide? Yeah, sorry. So that is definitely something we are looking at now. We're still trying to get a sense of the scope of the rules, right? Because there's one piece of the information blocking is making sure that patients have access to their data, which is more straight forward and not the area that you're talking about. The other is what access it gives other vendors potentially to the data. You know, someone looking at doing a notification tool or something over and I think we're still trying to understand the scope of who this rule includes to get to a better evaluation. So I can absolutely come back and report that next time that we have a better, a more clear sense of what that means. Okay, great. Thanks. Any other questions? I don't believe so. Well, thank you very much. Now I'll hand it off to Carolyn, who's going to provide an update on collaborative services. Thank you. Hi, everyone. Bob, you can go to the next slide, please. So the collaborative services project was started in 2019 was diva vital and the HIE steering steering committee members. They had three main goals. You know, one was reducing the redundancy in health IT expenditures. The second was improving the technology, the HIE technology. And the third was expanding the capabilities for new data types. Next slide. And the way we've approached this is we broke this into a few phases. Phase one was three building blocks of the future ecosystem. And we've completed this phase and included a new universal master patient index tool that improved the duplicates and specified population matching rates from less than 65 to overnight. And it also included an interface engine that we moved from on premises solution to a hosting solution that gave us some disaster recovery capabilities and also unlimited end points to connect to other outside entities like healthcare organizations to exchange data with. So that sets us up well for the future. The third piece was a terminology service engine that we've implemented and we've been able to we have nine concepts mapped and over 700 unique codes for those nine concepts. Data concepts could be a one C, for example, or a cholesterol test. And in just in the month of August, we for those nine concepts, we inserted over 6600,000 codes into data on behalf of organizations that just aren't capable of doing this at this point, and that helps standardize the data for all things downstream. So, so happily that that phase is in the books and we have moved on to the next phase, which is phase two, and if you can switch the slide pop phase two is in progress right now. We are in the middle of implementation and you know our target is January is as Beth mentioned we are slightly delayed, but we're still hoping to have an initial release in January and then subsequent releases after this. And we will keep you apprised as we keep coming back on the progress of this. The charter and the requirements document were approved by the HIE steering subcommittee that's been convened to kind of help us through this progress process. Next slide. So the expected outcomes for the overall project include better data to support health care and health care system improvement more efficient data access for clinicians through some fire API support that's coming. API would be an advanced programmatic interface is an automatic way to exchange data. Improve data access for VHS stakeholders and support for patient access to data is a possibility more efficient and sustainable technology platform for the HIE to support and a very strong security and compliance position with especially in regard to all these interoperability rule requirements. Next slide. The initial implementation. We really want to, you know, implement these new technologies. We want to get the historical and real time data into the system. That's kind of a key piece. The first steps are to provide data to the blueprint and the one care Vermont who are two of our major utilizers of data in the health reform system. And we're also planning to create a data quality dashboard, which will be based on the vi connectivity criteria that you get to see and approve as part of the HIE plan. And then we're also trying to support the ONC and CMS rules compliance that Christopher just talked about. You know, those are kind of the initial goals. And then next slide. And then our near term robot because, you know, the one thing to remember about this project is that it will have many phases and many releases over over the course. This will be, you know, similar to our existing technology platform. This will be a never ending process of improvement and a new functionality being rolled out. So the near term roadmap includes putting in place the building blocks to be able to support the sensitive data ingestion that we're talking about. And then also implementing the functionality to make sure we're in compliance with the ONC rules. Longer term. Next slide, Bob. There are lots of areas of opportunity and we're working with the HIE steering collaborative services subcommittee to kind of review and validate which direction should we be focusing in first Longer term and to develop that roadmap. Are there any questions on all of that? I would just make a comment, Caroline. We try to have an acronym free zone here. One of the purposes of the Green Mountain Care Board is to get information to the public and it's pretty hard for us to simplify things for the public when we can't even figure out them for ourselves. It's like FHRR3 and things like that are very tough to comprehend unless you're living in your world. Absolutely. FHIR I can clarify is fast healthcare interoperability requirements. And so that is the new data interoperability transport standard that ONC and CMS have developed. And they're putting in requirements to force people to use those standards. So we need to get those standards in place and we'll be that's part of this new platform enables all of that. We can also take under advisement for next presentation. Absolutely. I would greatly appreciate it. Yeah. Good feedback. Thank you. And if it's helpful, we can, I can go through this section and write something up and send it to the Green Mountain Care Board after the meeting. That would be great because when we post a slide deck like this, it's pretty hard for people to click on it and really understand what it's even saying. Okay. So, I mean, I'll, I'll just second what Kevin said in my notes from reading the slide deck before today. This meeting I had in plain language, please. So, because, but I did have one question. When you on slide 19, when you were talking about December 100 codes being mapped, I was wondering, is that include kind of geographic mapping of those codes? No, that data concepts. So for, you know, like a diabetic A1C test, there can be over a hundred different ways that a clinician can report that based on the type of test, type of A1C test it was, was it a fasting test, was it a non fasting test? So there could be over a hundred ways that they can report that from their EMR system. So we have to look for each of those textual codes and turn that into a standard code set or a standard code for each test. So it's not geographic mapping. It's mapping from the word A1C that's being sent to a standardized code set like Loink, which is a lot. It's a nationally recognized laboratory coding system that you can say the text A1C equals a fasting test given by a provider at this location and it equals, you know, one, two, three, four dash five. And so you would put the one, two, three, four dash five into the data and that would allow everyone to know that that test is exactly this on the standardized code list. Thank you. I had a question to related to that. In terms of the terminology services, your slide indicated that you had nine concepts that you had mapped. Is there a kind of a universe of concepts that you eventually would want to map to or obviously it seems like certain types of information being exchanged would be more important than others depending on how that information is used by the clinicians. I'm just curious about that it's nine out of how many eventually and how did you pick the nine where they just simply the ones we were reporting for was more work down there? Yeah, so the nine concepts were really developed in conjunction with our downstream stakeholders who use the data for reporting and analytics. And they were mostly, I should say they were all based off of the quality measures that either the ACO or the blueprint or the Vermont CARES product care initiative are trying to meet with the data. So they're really, they are really focused right now around primary care use and they include things like cholesterol, A1C, we just added recently depression screening. That was a big one that people were looking for. So and as we move forward, that's the same, they have the same input as to into the future coding needs. Some of it is a blend of what systems, what is not being sent. Our new system allows us to see the data coming through it in mass and identify which codes are we, what data are we seeing? A lot of it does not have codes in addition to being able to take that and work with our stakeholders to say, all right, here's a lot of data we're receiving that doesn't have a standardized code. Which ones are your top priorities or your next top priorities? So that's, that's how we're developing our prioritization. Great, thank you. Thanks, Carolyn. Hi, I'm Bob Ternot. I'm the CFO for Vermont Information Technology Leaders. And I just want to thank the board for allowing us to speak on these topics. Just working off of what points Carolyn noted, these projects were envisioned to rationalize or consolidate data platforms, which would result in real cost savings and cost avoidance for a number of our stakeholders. Over the next several slides, I will show you the results of our analysis on cost savings to address the board's question on system cost savings from the collaborative services projects. This analysis is the collaborative process product of discussions between vital and diva on system savings. The methodology that was used for this analysis included the values are shown in current year economics. They reflect incremental cost impact of the project. Many of the values shown are vital's best estimate and may not be necessarily a final number because either the effort is ongoing or we just don't have the operational history to be more definitive. The investments shown are the one time charges to deploy the tool or the system. And the annual cost is one year's ongoing cost, which may include the subscription fees or additional vital labor to maintain or operate the tool. We've defined cost savings as those actual costs no longer required because of the project that has been implemented. Cost avoidance has been defined as those costs in the future, which have not been incurred and can be avoided by this project. In some situations cost savings and cost avoidance could not be assessed because, again, we just didn't have the information since we were still in the process of implementing these projects and don't have the experience with the operation of the component that's being assessed. Some of the savings that we've portrayed represent the maximum possible, so we will need to realize that as we operationalize these tools, we may find that there are costs which we haven't estimated, which may negate some of the savings that are shown in this analysis. Given this, and as Beth has mentioned, we plan on revisiting this analysis in the future. I checked it on the web. In summary, we see direct annual savings of almost $1.4 million in savings from these projects, along with $375,000 of one-time cost avoidance and over $200,000 of annual cost avoidance. Okay, I'm going to move on to my next slide. The Master Patient Index Project, or MPI, is a clear example of the intent of the collaborative services projects to enable multiple stakeholders to use a common tool and avoid replicating cost and effort. We did not estimate direct cost savings because this really doesn't replace the existing patient matching functionality which is embedded in the legacy V-High system, which we are not replacing. The implementation of this tool, however, has yielded immediate results, such as the improved match rate that Caroline mentioned, along with enabling vital to support requests for ad hoc matching from stakeholders and saving stakeholders from burdensome manual matching efforts. The terminology service project, we did replace our existing terminology services tool with one in which we see as easier to operate and more reliable. In addition, this tool provides the ability to tag different data types. The cost savings that are shown here represent the cancellation of our cost of our contract with the existing terminology services tool. The cost avoidance represents the costs necessary to upgrade that older tool to make it comparable with a cloud-based tool that we now have engaged. If you add those to the cost savings and the avoidance together, they would equal the annual cost for the new terminology services tool. The Rhapsody Interface Engine project represents a new approach to how we handle interface paths. It is foundational for our other collaborative services projects. While the savings shown is minimal, it's because we're really not replacing something else. We are adding new functionality to the Vermont Health IT ecosystem. Its key benefits here are it enables disaster recovery, it strengthens security, it's a hosted solution which eliminates local infrastructure needs, and it is more appropriate for handling sensitive data. The new data platform is a project which really represents the streamlining of fragmented data platforms throughout the Vermont Health IT ecosystem. Vermont recognizes that the state has made a significant investment on this project and we believe it represents their confidence and vital to make this happen. This project creates the ability to ingest or incorporate other data types and other data repositories. It implements more current technology to support robust data reporting and access. It also provides the largest cost savings of the four projects at $1.3 million. While it is shown at a maximum, it doesn't consider, as I mentioned prior, any increased costs due to operations since we just don't have any experience with its operation right now. We're just in the process of implementing this system. It does enable vital to meet the interoperability rules that Christopher spoke about without additional investment. And it eliminates an inefficient, self-developed infrastructure, which while for its time filled a critical need for vital, it has been leapfrogged by industry offerings. And to conclude, the new platform and tools offer vital and our stakeholders possibilities to expand to other data types, including such things as social determinants of health. Assist others in meeting the federal interoperability rules, it streamlines our functionality, and it extends the use of the master patient index to other partners. Vital will update this analysis regularly to reflect new information as it becomes available. Are there any questions I can answer? Any questions from the board? I mean, I have a question on the new data platform page, the one prior to this, where you outlined the costs and then the potential savings, a lot of which went to diva and blueprint. And just wanted to understand, I guess who's paying for the initial, I think it was about $2 million in cost for that. And how will you recoup those, you know, the benefits that will go to other parties or how's that? Let me address the first part of that question. The initial investment was $2.1 million, and that really represents the contract value of the project to implement and deploy this tool in our CY20 contract. It includes both vital and the vendor's implementation. With regard to future benefits, I guess that's going to, we are going to have to continue to assess the benefits as they arise through discussions with diva. The cost savings that are shown here really represents the incorporation of the VCR into the new data platform. And the cancellation of a contract for the maintenance and operation of that data repository. Okay. I mean, it would just be good to see you be able to get the benefit, some type of benefit from the savings that you're able to get for other parties. Yeah. So Bob, do you mind going back to that slide? Sure. Thanks. So I think that's a great point. And I just want to, I think maybe clarify one piece is, so we've traditionally been providing some of the data to the blueprint that they had an outside vendor and diva was paying for us to have a platform and paying an outside vendor to then process some of the data. So it's actually saving some funds for diva on that end. So we, we are not losing out. I mean, we are still benefiting from the work and getting a much better platform, but they are streamlining some of their expenses. So I would say that we've benefited from the new platform and the kind of continued sustainability that that will provide us when it comes to the one care piece. This was less where they, at this point anyway, partake in the platform, but we do reporting for them that we do have a contract with them to provide that reporting. And this is going to make us be able to do, Caroline, correct me if I get this phrase, but I think more robust and more effective reporting for them. So I think that maybe some opportunities going forward for both of us to have improved. This is Robin. I had a follow up. I think, and you may or may not know the answer to this bet, but I think both the money that blueprint was using to hire that vendor and the money from your contract both come out of the HIT fund, which is taxpayer funded. Yeah, so it is a combination of CNS funds and they use the HIT fund to do that. I don't know each. I don't, I don't want to quote if they're going to my 510, but yes, yes, you're absolutely right. Okay, thanks. Could you flip back to slide 25, please? Just want to make sure I'm understanding what I'm seeing here. So I, let's see. So I kind of looked at this, you know, as a kind of a summary, and then the subsequent slides is some of the elements of this that correct way to look at it. Yes, it is. Okay. So I'm just wondering if, if in this presentation, you could put some kind of a net so that there's a bottom line overall, because it says, you know, we estimate the investment immediately. So you have investment, and then you have direct annual savings and cost of ordinance and those two, if they were netted against each other would just be a helpful bottom line to say, and in totality, you know, this is this is this is why these investments are good. I'm just thinking, you know, what the simple story is because things always pop up where someone says, oh, we're spending all this money on these new systems and stuff. And, and, and there's no real payback, etc, etc. But the this page of netted would be able to say and the net amount of savings to whoever whether it's diva or you or the Department of Health is is is the bottom line new as as you roll this out. But thank you very much for doing all this is very helpful. You're welcome. Oh, one more question. Quick one. So I saw one of the slides that the match right now is that kind of a 95% confidence level versus the 65 was it was that just a placeholder number or is that where you're matching is at these days that you're 95% confident that I guess as a way to express it that what you see is what it what is real. Yeah, so that number is based on a few kind of reference populations that we use it's hard to say across the MPI, a good matrate but so we take a couple of reference populations that we do reporting on. And it's a very specific number. It's not it's not an estimate very specific numbers of prior to putting the new MPI in place with a matrate was around 65% and we're seeing matrates on those same populations at over 95% now with the new MPI. Great. Thank you. Any other questions from the board. Hi, this is Caroline again. So we want to give you a quarterly update that you've seen before but we have a few small updates to the slides based on some of your requests. So next slide please. This is the percentage of Vermont patients opting out of the V hi, as Maureen mentioned before it's, it stayed fairly consistent. A little last few months, since we've made the switch in March. Next slide. For the file access queries this is a provider portal. We've broken these up by types of organizations that are accessing the data as this has been requested of us. The, the main state agencies that are this are the brown on the top three. This is a remote care initiative and the state epidemiology department at VDH who are doing some of the contact tracing. And much of the hospital usage is in the emergency department. Next slide. Now the cross community access are ways of getting at that data in the provider portal, just different ways that are more automated for those descending facilities. The Department of Defense and the veterans administration are the primary users of this through the cross community access. As they don't have any way to get data outside of their system, but this method. Next slide. This is results delivery for laboratory radiology and transcribed reports. And as you can see the data dipped in April due to COVID and the reduction in health care services that were being offered. And then has started to rebound as more of the practices and providers start trying to reopen their, their businesses. Next slide. This is the same results delivery just broken up by provider type. So we have 552 providers with this service and we've broken them out into what organization types to those providers belong to. Next slide. Before you move off that slide. I hope for me to tell the large yellow. That seems to be the predominant provider type here is that state agency or is that QHC they both on my screen look the same color so I'm just clarification. That is FQHC. I can just point out just the order that they are in and the legend on the right matches the order of the colors on the diagram that has helped us internally. Thank you. Yeah. Okay. Next slide. On the interfaces and connectivity criteria, we have been working with Vermont care partners, the designated agencies and others on the HIE steering subcommittee to develop new connectivity criteria for mental and behavioral health data. And then incorporate this into the existing criteria. We've been working with the HIE steering committee in September and will be included in the state HIE plan being submitted to you in November. This helps is one of the building blocks to set the stage for accepting the data next year. We've also completed 62 interfaces as of June. But I will say all the new work that we're doing in this area right now going forward is really focused on the state COVID reporting needs. And we're working closely with Diva and the Department of Health to align all that work to support the state state needs for data. And you know, tier two and tier three just have not been a focus for us this year due to resource constraints at the healthcare organizations due to the pandemic. Next slide. Meaningful use and security risk assessment consultation. We've just continued to our ongoing supportive providers for their needs as they as they come up. And we expect that to just continue throughout the year. And that is the last operational update questions on any of those. I don't believe so. Would you mind if I ask words that break down helpful for everyone. We'll continue doing it that way. Great. Thank you. Okay. Thank you. Hi, this is Bob turn it turn it over again and I'll conclude our presentation with an update on our FY 20 financials. Our audit is still underway. So the numbers that you are seeing may vary somewhat from the information in our final audited financial statements. Overall, we perform better than we had projected in the FY 20 updated budget in terms of net assets, even in the light of the disruption of some of our projects due to COVID-19. The full year revenue was 6.9 million. And that was lower than our updated budget by $700,000. The significant driver of this was the impact of COVID-19 on our health care clients, their ability to work with us on connectivity projects as Carolyn has previously described. Well, we have received approval for the state to repurpose some of our CY 20 contract funds for COVID-19 efforts. We estimate that we will be able to reallocate perhaps over a half a million dollars of these monies to fund ongoing COVID initiatives. And we expect that this revenue will be realized in FY 21. We were able to underrun our expenses for FY 20. The significant drivers were our lower labor expenses of about a quarter of a million dollars from yet to be filled positions. Lower expenses from the delay or postponement of technical projects due to the COVID-19 pandemic. In the areas of consulting data security and be high connectivity costs and network services. Some of the delayed work though is included in the approved FY 21 budget. In addition, we did not need to utilize the $150,000 of contingency that was included in the updated budget. In total, the change in net assets was $700,000 for FY 20, better than $900,000 than our updated budget. Cash is robust at $3.6 million as of the end of the year. This represents 210 days of cash on hand. This is about $700,000, a little less than $700,000 more than our projection in the FY 20 updated budget. This was due to the receipt of a large diva payment in June, which we had expected in the budget to be received in July. Conversely, our accounts receivable receivables were lower by about that amount reflecting the conversion of this cash. That is the totality of my presentation on the preliminary FY 20 financials. We expect that our audit will be concluded in mid-November and we will provide the final audited financial statements to the Green Mountain Care Board in a timely fashion upon their completion. Bob, can you remind us which auditing firm you're using? Gallagher Flynn. Okay. How many years have they done it in a row? I think this is the third. Okay. Questions for Bob? It's great to see the strong cash position that you're able to have. When you talked about the delay, I know, Beth, you started out initially talking about the delay of implementation. What's the expense cost going to be for that? Usually when we have a delay in a project like that, but it usually costs more money, which probably is coming into your 21. But do you have any idea what that will be? Yeah. I don't know. We're still scoping out what the delay really looks like. You know, we're still, we're kind of chunking our go live into a few pieces to make sure we can hit the kind of drop-dead requirements we had. We do think where we will see some additional costs, and again, we are trying to scope this out now, is we're going to try to bring in some external resources to help us speed the project back up to hit some of those dates. I do also realize that we have a couple of, we had budgeted some consulting to assist with the project, first of all. But also, just so you know, because actually an interesting, a good piece of information for you to have is we were able to work with DEVA to repurpose some of our current year deliverables to find some of the work we're doing with VDH. So even though the healthcare organizations haven't been available to work with us, we've been doing a lot of interfaces for them to get them the data they need. So that is hopefully going to lead to some revenues that we hadn't budgeted for this year that will offset some of the additional expenses too. So I'm hoping it's not, there'll be impact to the budget, but I don't think it'll be an excessive impact to the budget. Okay, thank you. If I could just add one more piece to this, the contract with our data platform supplier, the implementation cost, is a fixed price contract. So any delay won't necessarily be a cost impact and initially too vital. I just thought I would pass that along. Okay, in that area, but if you need to hire additional consultants to help get the project back on track, it's going to add incremental cost. Right, or it could take time from our team from other deliverables and impact other projects. Okay, so that may be an overall impact. I'm sure you're on top of that. That was a good question. Always when you have delays, there tends to be extra costs. Thanks. Other questions? I just want to reconnect a little bit to the past and kind of look to the future. And my memory could be failing me here, but I remember, you know, Mike Smith coming in and saying that he was going to build carry forward in like 2018 and 2019. And that 2020 was a year where that carry forward would be expended. And during that period, then vital would need to be building kind of new revenue or enhanced revenue resources for ongoing sustainability. And so I'm looking at this $3.6 million cash on hand and that seems far in excess of anything that I can recall and I haven't looked at this stuff in a while, but and all of this stuff is at my office where we don't go anymore. You know, so I'm just wondering, I thought that coming into 2020 that the cash on hand was going to be around a million bucks and that was going to be expended. But it sounds like you're in a far better position than you were projecting in 1920. Yeah, I think that's true. You may want to correct some of this because you have more history than I do, obviously. I think some of it's due to the contract for this past or this current sorry calendar year with evil was they were able to obtain additional more CMS funding with the collaborative services project really drove some of those changes, I think, and some of the projects we're doing. And so I think that that has driven some of the ability to maintain a little more cash on hand and push that off. We absolutely still have to be focused on what our sustainability is long term and the investment in this platform is going to help that. And part of the reason for that is in September of next year, the CMS funding sources really shift the old funding program expires and retires. And we move into new and kind of unknown potential funding. So we really are focusing on next year being a shift in that. So I think you will start to see see changes on that cash and hands probably just a little delayed from what the original timing on that was. Thank you. Other questions. Hearing none at this point, I'm going to open it up for public comment. Does any member of the public wish to comment on the vital presentation? This is Rick Doolie. Correct. I'm just curious. I know that for one of the biggest problems that we've had, certainly as practices with vital access is just any time there's another platform that we need to use to try to get the data. It just creates a barrier in terms of just office flow. How I saw the stuff and not interoperability and with the new, you know, each other vacation. How close are we to getting to the point where data flows freely, bidirectionally the lab done in my office be able to drop into the electronic record through vital at UNC and vice versa. Caroline, do you want me to take that? This is Caroline. I'll bear with you. Through some of the new interoperability standards, the fast healthcare interoperability standard or fire, we will be able to do bidirectional. And so next year will be the year where we'll be able to start implementing those and some of those bidirectionality will depend on the practices in the hospital's readiness for that new standard as well. It has to both have to be talking the same language on either side. And there are a few. Is there support for the interface development for that through vital or is there any, is there going to be any financial support for practices for that, do you know? Yeah, so the way that it's working is most of the certified technology that's being used at the EMRs are going to be required to support that standard. What they charge practices to utilize that standard? I don't know. These are also, we don't have answers to this. I think right now these are conversations we are having with the team at Diva though to figure out how we incent this transition to, because I think we realize there is a cost on both sides to make some of these transitions. So I'm sorry I don't have a specific answer, but it is something we are talking about. Yeah, and we are making the other area that we are making moves towards is some of the national networks. We do have a connection to the e-help exchange currently and that allows us to connect to care quality and commonwealth sometime next year once we've gotten through their upgrade process. We need to get to a newer version of that and we're in the process of that right now and once we're there then we can investigate joining care quality or commonwealth which does allow providers if their EMR supports that to natively go out and query those national networks. So that's all kind of in discussion and implementation phase right now as to what that looks like next year, but that is another way without having to go to the new standards that people can use some of the existing things that are within. With any MRs right now. Thank you. Yeah. Thank you. Okay, more Wasserman. Hi, thanks. I wonder if we could hear a little bit more about the work with the Vermont Department of Health, specifically in two areas. One is the way that you've been able to help VDH report on COVID patients, specifically accessing data on disparities, which would have been very hard to get any other place how you've been able to do that how you might be able to continue to report on disparities and after the pandemic is hopefully gone. The other thing would be about immunizations, which is going to come up in the next year and how that will work by the registry. Thanks. Caroline, I'll start. Well, I'll start. Dr. Wasserman, you've heard me say some of this before, so I'm sorry. Some of it may be repetitive. You know, with some of the work to date with VDH and particularly around and you may have seen they did some releases about this earlier on in the pandemic. They were able to help them populate race and ethnicity data that they weren't able to get otherwise. So I don't remember the exact numbers, so don't quote me and you may have them more clear than I do at this point. But they were getting, they were seeing pretty poor ability. I think it was more like the 20% range and they were able to complete on their patient records when they were doing the reporting on positive cases and where they could identify a race or ethnicity. They were able to give them access to data in the V high on those patients and just being more robust and more diverse sources of data. They were able to get that I think up into the 70% range that they were able to populate that data and really get a much better sense of the impacts of the pandemic across the population. Thinking forward, you know, Carolyn will probably have more, but we are working with them. So we do get some of the immunization data now and feed that to the registry, but much of the data goes directly into the registry and isn't in the V high. And we're trying to work with them to identify ways of getting more robust data into the V high so we can make it more available for both for providers to have access to that data or more patients have more ready access to that data. Also to make a more complete and holistic patient record available. So really so you have the public health data with the clinical data in one place to both do planning and clinical care on an individual basis, but really to think more across the population as well. Carolyn, would you like to add anything or correct anything I said? No, I mean, you know, we're we're definitely part of the meetings that are happening at the statewide level right now with the age trying to lay out what does the vaccination plan look like for for Vermont and trying to make sure that the V high and the immunization registry can get all of the vaccination data for COVID vaccines to support all of the reporting that we know is going to be needed. Right. So I just if I can just comment the ability to find out race and ethnicity data that be highs been able to you folks have been able to get out of the high is, you know, somewhere around an order of magnitude greater than can be gotten at a V cures. And in a season where health disparities, race and ethnicity are ever more topical. It seems like the be highs has the potential to be a great resource for the state in tracking health disparities, not just in COVID 19, but in the many other other areas where health disparities exist, and which they're right now impossible to get out of each yours. Just a comment. Thank you more. Other public comment. Good afternoon. This is Susan air enough from the Vermont about mental disabilities Council and following up on what more just said, I wonder what somebody could speak to the greatest group in Vermont in terms of health disparities are people with disabilities. And the rate of chronic conditions amongst people with disabilities tends to be literally to sometimes three times higher than other people, whether it's diabetes heart conditions, etc. Has the high figured out a way to identify people with disabilities in terms of population health metrics. I think it would have to say, I don't have a full history so someone on the team may have a different answer. But I think our answer would be no only in that that we don't tend to focus on the analytics and the population health aspect of the data and ours is more around the accessing and making the data kind of usable and quality for our partners who would then be using the data to do that sort of analysis and work. But in terms of demographics, like I think I just heard you say that you were hoping to be able to contribute to the work on health disparities and so with health disparities you're usually looking for demographics like race or ethnic information and perhaps socio economic information and I would think disability related information. Is that something, is that not happening at vital, are there discussions around that with public health department? I don't think we've had discussions on that specific topic at this point or you know this was early in the pandemic response where they were trying to get a broad swath of understanding of who is being impacted. I think it's probably a conversation we can raise with them. I don't know if they've been digging into that necessarily because they do have access to our data so we may not be aware of all of the work they're doing on the analytics side with the data that they have. And I do, Susan, this is Caroline. I do know that VDH has been reaching out to Dale as part of the vaccination effort. So, you know, I can't speak to the conversations there but I know that those are happening as part of the overall vaccination effort. That's useful. Of the about 85,000 Vermonters estimated to have a developmental disability, what would mean a federal definition of developmental disability, only about 3,000 received services through Dale, but it would be great if Dale were tracking by disability. We understand someone's keeping track of somewhere of people who test positive, who receive services, maybe and maybe it's under 11 in one set of services. But to my knowledge, no one is really tracking that within AHS yet. But thank you. So disability data, they might be tracking with AHS race data. I believe that they are. I don't think anyone yet is tracking disability. And part of that, as you could well understand, is how do you define someone with a disability? How do you flag that? Yeah. So easy flags tend to be, are they receiving home and community based services for disability? They could at least share it there, but to my knowledge that hasn't happened. Yeah, I think it is. It's absolutely possible. I think the hard part, as you mentioned, is exactly that. How do you define disability when we don't have access to that AHS data that says they received this service? Yeah, exactly. A future project. Thank you. So I just wanted to say thank you for that public comment. Hearing none, I'd like to thank the team from vital for the update today and looks like things are moving in a very positive direction and keep up the good work. Thank you. Thank you. Thank you. Thank you. We are going to transition over to a discussion on regulatory integration and I'm going to turn it over to Sarah Kessler. Before Sarah, Mr. Chair, I was going to tee this up, but Sarah, did you want to say a few words first? No, I was just going to say that. So I just want to give a bit of a background on how we got here with this series of white papers. I want to talk about the goals of the project and then the audience and then we'll turn it back over to Sarah who will get into all of the details. So the background of these white papers was that for quite some time regulated entities and stakeholders have been asking us about this topic. How can you integrate your regulatory and align your regulatory duties at the board? So the board formed an internal team led at the staff level by Sarah Kinsler who is our director of strategy and operations and she was joined by two board members, Jessica Holmes and Robin Lynch and they worked on this series and Sarah will get into the details. They worked with stakeholders and others to create this really excellent white paper series on regulatory alignment. The goals and again these are high level. Sarah will get into them in more detail. The goals are really to streamline, to attempt to streamline some of the board's oversight so that the regulatory processes can continue to inform each other. I think we heard a little bit of that even yesterday during our hospital budget reconsideration work. Also to develop measures where they're feasible to allow for comparisons across the regulatory processes at the board. And then just to in the future envision potential future agreement and care board regulatory processes as we continue down the path of moving away from the first service toward value based and population health programs. And then I'll just close by saying the audience for these papers. They're they're obviously open and available on our website open to the general public, but they are quite wonky. So I'll just say that the target audience are the the the very engaged stakeholders from the board, the advocates, the regulated entities of course policy makers, such as at the legislature and other state government agencies and then last but not least media. So, I will turn this back to you, Sarah and just a shout out a thanks to Sarah for her fine work on this and also to just just and Robin for their work on this white paper series. Thank you so much. Can you all hear me well. Yes. I am I am at the very quiet green mountain care board office. No one else here today. So I'm not quite my usual setup for the record. This is Sarah can clear the director of strategy and operations at the board. Thank you so much even for that introduction. I just want to say that it's been a real pleasure to work with members homes and loans on this project. It's been a pleasure to be presenting it to the full board and to our stakeholders today. The goal of today's presentation is really to share the drafts that we've developed as the first two white papers in the series, which cover our current state. And just some options for changing our regulatory timeline so that we can invite comments from the board and from members of the public. These discussion drafts have been posted to the GMCB website for quite a few weeks now for public comment really since the summer and will be soliciting public comments on them through the end of October. This is just extended to offer additional time. So these slides will link to the public comment page on the board website embedded in a couple of places. You can find it on the website directly. And we really hope that anyone who is who is listening and who is interested will people look and share their thoughts so that the final white papers can be as robust as possible. I'm going to quickly walk us through the content of the white papers themselves and just focus on the connections across the regulatory processes and the first paper and the options for timeline adjustments in the second paper. And then we'll talk a little bit about process and future work. So if you quit on the right side, if you go no further in this presentation, the three things that I really want to highlight today. Our first differences in population services and payers make it very challenging to compare regulatory processes directly. We really need to focus on size and scope when we try to estimate the impact of one process on another. Secondly, data availability drives our current regulatory timeline along with state statute and federal requirements, and this is a major barrier to change. And last, there are important connections with other state of Vermont agencies and with the federal government across our regulatory processes that we need to keep top of mind as we consider changes. So the first white paper, our first white paper focuses on documenting the current state and the connections across processes, which in many cases are multilayered and bidirectional. This is also where we start to talk about those intersections with other agencies. As I mentioned earlier, we're going to talk about four processes used today. The all pair model, focusing on achieving the ACAM targets and on GNCV's regulatory role. ACO oversight, very current to what we're heading into in the fall season. Hospital budget review and health insurance premium rate review. The white papers also include certificate of need, but I left it out of the slide back just because it really is most related to hospital budgets and we want to stay pretty focused today. So brief process, we're going to walk through some key metrics to give you a sense of the scope and the impact on the full health care system. Not new information for board members, but I want to make sure that I'm setting the stage for the public in terms of how the Venn diagrams of our processes overlap. On the all pair model, there are three key pieces here. First, achieving the all pair model targets. The board is not solely responsible for this. Rather, it's something that all of the agreement signatories, so the board, AHS and the governor's office have committed to striving for together along with our private sector model partners. The board has a significant monitoring role here and it's responsible for a lot of reporting on the state's progress relative to targets. So, so far we're performing all right on total cost of care with 2018 data only, all right on quality of the room for improvement again with only 2018 data. Quality revolts for 2019. It's on the agenda for the board's meeting on October 7th and 2019 total cost of care results are coming in later this fall. As the board is aware, the state received a warning letter from our federal all pair model partners recently stating that we have not yet achieved the scale targets set out in the all pair model agreement years one and two. This was not expected and in fact is based on a report submitted by the board staff to PMMI in June, which anyone in the audience can find on our website on the all pair model reports and federal communications page. We've also posted the letter itself to that page. So staff are going to be working with the other agreement signatories to draft a response and that will be submitted by December at the latest. The all pair model agreement also grants the board the authority to propose modifications to Medicare's national next generation ACO model to create a Vermont specific Medicare ACO program in performance years two through five of the all pair model. That's 2019 to 2022. This sheets the contract between the ACO and Medicare and really the intent is to support a line across chairs. In addition, the board has the obligation to propose the Medicare ACO benchmark or the standing target to see my my annually. So in terms of size and scope, the all pair model includes a significant minority of our monitors that 220,000 and 2020 for payers. The agreement itself is really focused on Medicare, but other payers also participate in aligned ACO programs and again alignment and the multi pair approach are pretty critical component of the model. The model targets that does the best include all pair targets and quality measures that consider all the monitors, not just not if there are any for services. We're looking at Medicare, a and B equivalent services. So that's hospital infusion and outpatient and traditional services for spending. According to our 2018 expenditure analysis, which was released in early July, about 46% of total Vermont resident health care expenditures were included in all pair model total cost of care. So a note about spending, we've included this figure where, where we can in an attempt to help us tease out how big a piece of the pie we're talking about. But I do want to point out that there are two different denominators that we've had used for different processes and depending on the data. And the expenditure analysis total Vermont resident spend as we've used here. So that's an increase services provided to for monitors no matter where they occur. And then conversely, the expenditure analysis total Vermont provider spend so for spending for services provided in Vermont no matter who the patient is. And these are not comparable. So I'll try to know where we've done that. And then for each process, I'm going to end this key takeaway. So pretty all fair model. Supporting achievement of the APAM agreement goals is a major consideration across our regulatory processes as the board knows. And in our non regulatory efforts, for example, our data work. Monitoring work and reporting are a huge part of the agreement. Our board's responsibilities under this model and something that staff is significantly engaged in. Secondly, all care model regulatory levers, the benchmark in the medical program modifications also significant interactions with other processes, especially a fuel budget review and hospital budget review. And finally, our key partners here as a co-signatory and as a payer participant in the model through Vermont Medicaid next generation. I also just want to note that I've included timelines for each of the individual processes as resource slides at the end of the side that for anyone who wants to kind of get into the nitty gritty of how each process progresses throughout the year. So now we'll move on to a field oversight. There are really two separate pieces of GMCB's ACO oversight for first certification by statute and ACO must be certified by the board to be eligible to receive payments from Medicaid or from a commercial insurer through a payment reform initiative, including the all care model. Certification ensures that an ACO's policies and procedures need those statutory requirements. And after initial certification is granted, the board verifies continued eligibility for certification annually. Secondly, budget review. The board performs an annual financial and programmatic review of the budget for each Vermont ACO. The board also monitors the ACO's budget and performance throughout the year to ensure that there's compliance with any budget approval conditions. These eight ways here are that until we do achieve ACO scale, the ACO population and budget are pretty small subset of Vermont's total population spending. Without scale, the ACO's impact on all-care total cost of care and on the all-care model population health outcome measures will be more limited. So I've included two graphics here to start with. The first is 2018 data because that's the most current full year available for total cost of care. But below that, I've also provided a sense of how the ACO's budget fits into total projected expenditures from our expenditure analysis. And you can see that it's still a smaller fraction, even though the ACO program has grown significantly between 2018 and 2020. This is in part because the population remains small compared to the full Vermont resident population, but also because the services included in the ACO budget are more limited than those included in the expenditure analysis. I also wanted to note that there's significant interaction with the all-care model care, of course, because of the affordability to shape the Medicare ACO program and spending targets, as well as the hospital budgets, and I'll go into that more in a couple of slides. The big links with other agencies here are with DIVA, both through its work as a payer in the ACO program and as an agency that administers blueprint for health, as well as the DSR and its work around risk and reserves. So, hospital budget review has been in Vermont statute since 1983. Two key decisions the board makes. First, limits on net patient revenue in case of prospective payment growth, and secondly, maximum increases in hospital charges, which mostly impacts hospital negotiations with commercial insurers on their price list. So, here's really large. The population is anyone who seeks care out of Vermont hospital, including out-of-state residents. Payers are all payers, including self-pay. Services are hospital, inpatient, outpatient, and services provided at-own practices. And under spending in 2018, 42% of expenditures by Vermont providers flowed through the board's regulated hospitals, and I'll just note that that's the provider side of the expenditure analysis as a denominator, not the resident side. So, hospital budget review impacts a huge portion of the health care system and health care spending, though, as member Lynch often says, it is a blunt lever. In addition, hospital sustainability is a really critical issue here, and since these discussion drafts were first posted, the board has voted to engage all Vermont hospitals in the sustainability planning process. I had very briefly mentioned earlier the connections between ACO oversight and hospital budget review. Those are really ACO participating hospitals pay ACO participation fees, which fund a portion of the ACO's population health investments. Second, ACO participating hospitals take on risk. ACO performance and potential for risk or gain sharing in ACO care contracts then have the potential to significantly impact hospital spending and their financial health. And finally, ACO participating hospitals can choose to receive fixed prospective payments rather than fee-perserved payments on the health care distribution. Hospital spending and ACO participation decisions, which explain the hospital budget process also affect performance on the all-hair model agreement targets, so there's a lot going on here. And then finally, I just want to note that there are links to works by Diva and VDH in the hospital budget process. Diva through dish payments and provider tax, VDH through community health needs assessments, as well as a hospital report card. And I also want to mention that that GMCD set average commercial charge increase is also a factor in rate review, incorporated in the following year's rate analysis as the actual, through the actual claims. Last and not least for the purposes of today's discussion, rate review. The board is tasked with reviewing major medical health insurance premium rates in the large group and the merged individual and small group health insurance markets. The individual and small group market is mostly the qualified health time market. Generally, but in 90 days of submission, the board has to determine whether a rate is affordable, promotes quality care, promotes access to care, protecting sure-salt and see is not unjust, unfair, inequitable, or misleading, or contrary to Vermont law, and is also not excessive and adequate or fairly discriminatory. So the population here is much smaller than the previous process you talked about, just over 94,000 people in 2018. This is a significant decrease from just five years prior to that, about 40% decrease since 2013, when there were over 150,000 Vermonters insured in these types of plans, and that's due to growth in the self-insured plans and in public coverage. The payers here are Blue Cross Blue Shield, MVP, and State Math, and services are essential health benefits and Vermont mandate benefits. We mostly focus on CHP rate review here since it's a larger population, and it's an annual process with an annual timeline where as large group is having a rolling basis. Key takeaways about rate review, these processes impact a very small chunk of the total Vermont population, and in fact, the minority of the commercial insured population, about 30%. This means the ability of the rate review decision to impact other processes is more limited, and it also means that the rate review population doesn't have the same demographics or experience necessarily as the whole Vermont population or the populations that we impact through our other processes. One specific connection that I do want to note is that the QHP-ACO program trend is tied to the QHP medical trend approved by the board. But again, small population, about 30%. I think somebody is un-muted on the line. Again, I want to highlight that there are significant links to DFR's work here on former human policy as well as to do this work on Vermont Health Connect, and we'll see those things come up as we talk about them. Timeline constraints on a few slides. So what does this look like when you put it all together? It looks like a lot. This is a map summarizing our current connections and to speak to the people we'll get to next. Timeline and logistical issues, constraint and availability to have all of these things work together as seamlessly as they could. I'll say this looks busy now, but I know that in the telecom that we've received, we've already gotten other suggestions of things we could add to this map, so I think it will only a bit here. Before we move on, are there questions from the board about current state or part one of the paper? All right, hearing animals, steam right ahead. The second white paper focuses on the board's regulatory timeline and sequencing of our regulatory processes, which impacts how and when they can inform one another. I'll note again that I've included individual timelines at the back of the slide deck, so you can see they combine timeline on the next slide. This is an area where the board has received significant feedback from regulated entities and other stakeholders throughout the years and where there are potentially some opportunities we think for changes, but also significant external constraints. So this is the first half of the combined timeline. Full timeline is in the white paper, but it's so long-reality that it's on two sides here. Across the processes we just walked through, regulated entities have different regulatory seasons. That's the big thing that I want to highlight here. Different fiscal years, plan years, performance years. Two HQ rate reviews occurred in August for a January 1st plan year. Large groups have decided varied. Hospital budgets are set in September for an October 1st fiscal year start. And ACO budgets are reviewed in the late fall and decided in December. With the all-paramodal Medicare benchmark also decided in December for a January 1st performance year. And those are finalized in the starting when commercial contracts are at end attribution are known. In addition to those kind of very regulatory seasons, ACO budgets and certification monitoring, large group insurance rate review and certificate of need are always ongoing as a lot are too based on filing dates. So we long recognize that these regulatory processes don't exist in a vacuum. They inform one another and these interactions are only going to increase as the all-paramodal continues to drive healthcare systems from fever service payment to value-based models. One way to improve process alignment may be to adjust the regulatory timeline. Here's the second half of the timeline. All right. So the current timeline, there's definitely someone who should think I'm meeting. The current timeline creates two challenges to holistic the summary of regulation. First, the QHP rate review process occurs before hospital budget review, which means that hospital average commercial charge increases are set when premium rates are already fine while for the coming plan year. So instead of incorporating approved average charge increases into their premiums, insurers provide the impact of hospital's charge increase requests. Negotiated possible prices taking into account the board's allow charge increases are embedded in future years base spending as actual costs. Secondly, hospital budgets are submitted in July or present September before the ACO provider was finalized and also before the ACO program and the incentive details are finalized in the payer contracts. So trigger integration could make hospital budgets more accurate and would allow for multiple sites ACO oversight. The white fever itself has a deeper discussion of the timeline constraints and kind of why we currently do things the way we do them. But I'll just quickly mention a few of them here. One of the key themes and our data availability and the needs and requirements about their agencies and the federal government. For the all pair model, the Medicare ACO benchmark, the key thing here is Medicare data availability issues changing from that final ACO provider list, which is due September 1st in normal years. I should say that there are a variety of changes to the board's regulatory processes for 2020 in light of COVID-19 but these papers are really focused on kind of a normal regulatory year. So that final provider list is needed for Medicare to run preliminary attribution which is needed for the Medicare benchmark setting which is then key factor in the ACO budget. This year the provider commitment date was delayed until September 30th for Medicare. So things again a little bit different this year. Then secondly, under the all pair model of Medicare, the Medicaid advisory rate case, excuse me, the board is required to review the Medicaid advisory rate case before December 31st and the finalization of the DMNG ACO contract and the board is required to take this into account in this Medicare benchmark decision as well. For ACO oversight, the issue here is again data availability. The final provider list and preliminary attribution are critical for budget development and the ACO budget is not truly finalized until after the start of the performance year when insurance enrollment including the CHP's in Medicare and all the contracts are finalized. Achieving ACO scale will reduce but not eliminate population volatility. So we'll be able to estimate better but not perfectly as Sarah Lindberg has told me. Perhaps we'll budget this really a statutory constraint. Vermont Law requires hospitals use an October 1st fiscal year in alignment with Medicare reporting requirements. And then a qualified health plan read review is really a very multi-agency endeavor. So prior to the board's process, DFR reviews forms that are first from about March to June and is a very intensive regulatory process in itself. After the board's review in fall, DMN needs time to enter data into Vermont Health and Act and then to perform sufficient testing so that the system is ready for open enrollment on November 1st. Federal requirements including that November 1st open enrollment date are a major constraint for rate review. CMS and the IRS issue their guidance in the spring. And I'm told that that continues to move later and later in the spring. There are also requirements for January 1st plan year in merchant markets like Vermont. And again, open enrollment needs to start November 1st. So rate review is kind of closely hemmed in. So given all that, we made three recommendations in part two, most of which are really to continue to research, to explore, and to work with stakeholders to determine whether any of these options make sense and which we want to pursue. And the question here I think is really knowing that any change will require significant effort, particularly on the part of the board and regulated entities, is the benefit that we get from the change worth that effort. These recommendations were conceived prior to the pandemic. Obviously, any sort of modifications that require healthcare providers to be active stakeholders are going to be on hold at the moment. However, we think it's really important to put our thoughts out into the public sphere of the comments so that we can proceed in an appropriate time. The possibilities we've worked through here would be to move the hospital fiscal year to either January 1st or July 1st. And in either case, it would require statutory change, but there's an advantage to both, potentially. Moving to January 1st would provide hospitals with more certainty on the ACO-related portions of their budget and also more certainty on the ACO programs that they're signing up for. However, it could create some additional issues between hospital budgets and review timing since the hospital budgets would be presumably submitted after two-HP rates are finalized. So there wouldn't be the kind of requested rates to inter-rate into the two-HP filing. Moving to July 1st would allow hospital budgets to reflect six months of known ACO fixed prospective payments based on final attribution. So that was the first half of the fiscal year, the latter half of the calendar year. In addition, two quarters of approved hospital charge increases could be incorporated into the two-HP filing. However, this would also increase uncertainty related to ACO programs for the latter half of the hospital fiscal year, which would be the start of any ACO program year. The second recommendation, which is a little bit more, requires some more internal work at the board, is to explore using statewide data for the Medicare ACO benchmark, which would reduce the availability challenges and also allow for more timely cancellation, not tied to the timing of the final Medicare ACO provider list. The benchmark would also be more stable and predictable since the population would be more stable and would align with the all-care model Medicare total cost of care population and the labor years, the agreement ownership to being just the Medicare from being just the Medicare ACO population, the attributed population to the full Vermont Medicare population. However, the risk series that it could not accurately reflect the risk of the attributed Medicare ACO population, which is a concern since the benchmark is the financial target for the Medicare ACO program. And finally, we recommend continuing to improve how we communicate the impact of hospital budgets on CHP. One of the findings of the White Paper, which is discussing greater detail in the discussion graphs, is that the links between hospital commercial rate and NPR increases and the CHP premium rate increases is quite small in most years. This is a very consistent area of discussion at rate review and hospital budget hearings, including this year. And though we currently include information on this in the rate review decisions, the documents are not particularly accessible to most readers. And we think that there's some room for improvement in how we explain the limits of this connection. So, in terms of next steps, when appropriate, we will be engaging stakeholders to discuss changing the hospital fiscal year, recognizing that this would require some significant effort by providers, insurers, the ACO and state, as well as a statutory change. And we want to leave that timing PBD due to COVID-19 and hospital sustainability conversations that we're engaging in this fall. Secondly, we'll be working internally in early 2021 or starting in early 2021 to do some more modeling on the Medicare ACO benchmark suggestion using some statewide data as well as gathering input from SAM and my ACO before we consider a formal proposal. And in terms of process, so we've extended public comment that was originally welcomed through the end of September. We've extended that through the end of October. So, obviously, public comments have always opened up very much. You can visit the board's website to comment on the White Paper discussion graphs by the end of the month. Secondly, we'll be considering and integrating stakeholder feedback on parts one and two later this fall and planning to receive to release final drafts. And lastly, we're working on a third part of this series focused on policy alignment and not in development, likely to be released as a discussion draft similar to this in early 2021. The topics are going to include financial measure alignment, quality oversight, delivery system alignment, as well as risk and reserves and potentially other topics depending on kind of what we hear in public comment and what other issues come up. So, that is all I have to present. Are there questions or questions? Questions or comments from the board for Sarah? I just want to say thanks to Sarah for taking a very dense topic and condensing it nicely to explain the at the high level what's included in the papers. Other board comments or questions? Well, I know with a little piece of paper here as I was reading the study and then again here going through the slide presentation I wrote to myself, Gordian knot. It just is, you know, it's an entanglement. One area I'm just kind of, you know, a thought came to me is the sequencing. I forgot what slide it was, but the sequencing of the rate review for the QHP population and the hospital budget population. It's, I mean, there's some thought as to what should proceed what, what should have ascendancy. And there's a piece of me that thinks that maybe rate review should be the first step because that deals with affordability, which is a fundamental issue. And so before we get into hospital, you know, budget review, you know, having a rate review system not built on hospital to a great extent hospital expenses, but on affordability, especially since it's a relatively small piece of the pay or pie in terms of the number of lives it's covered. I mean, you had 94,400. I think we're down to like 77,000 for 2020. Something like that. So, and so just thinking about what should have ascendancy, what should drive the bus here. And obviously the QHP process isn't going to drive the bus because it's a small piece of the pie. You've got all the, you know, the payers out there, Medicaid, Medicare, the private pays, the self pays, et cetera. I mean, those are the ones, but I'm just thinking for the sake of affordability, which is a problem that we're trying to solve. It might be best to have rate review precede the hospital budgets so that the hospitals know what they're going to get out of rate review in the same way, you know, that they do their actual analysis now and kind of try to predict trends in the review mirror and then predict them going forward to know what they, you know, they might get out of other payers. Just trying to, just a thought, not a question. Just a little comment, son. When you look at the timelines that you set forward and then the new proposal, potential proposals and options, you know, it would be good to overlay the board's responsibilities across that because it seems on some of them that depending where we move, we may be overlapping quite a bit, you know, the hospital and the AC are over reviews at the same time. So just having an understanding of that piece of it. And I think, you know, clearly the hospital's input is going to be very important to this because, you know, if in fact they're going to need to change their fiscal year dates, you know, all the hospitals would need to do that. But I also wonder, I probably have a little bit of a different take than where Tom was going, which is because the QHP piece is so small, you know, I don't really see that as what should be driving the decision making on getting the rate reviews of hospitals so close, only because it's such a small piece of it. If in fact the ACO grows to where it potentially could grow to, I think having the hospital's input there on what's going to be best for them as far as that information, knowing, you know, for sure what's happening on the ACO, how important will that be to their process. And so they want to align it more closely there so that they can have the information from the ACO. It seems, you know, that may be one. And then, of course, you know, the third option or an option of just keeping it the way it is, you know, I definitely understand the issues and the timing, but also understand that budgets are assumptions all the way through. And so are we, you know, are we going to get a much better product at the end of the day while going through hoops to try to change everything? But, you know, there I would definitely defer to, you know, what other parties say when they go through this, you know, as to where they think it needs to be. I think, you know, we've worked with this for a long time. We've always had these issues. The insurance rate review is really a catch-up. I mean, you know, they don't know exactly what's going to happen because we haven't booked the hospitals yet. We haven't agreed to the hospital numbers. But at the end of the day, we know what happens. There's a catch-up and it becomes part of the rate, you know, at some point. You know, the ACO, there's been a lot of moving pieces there and things change even during the year. So, you know, eventually you do know during the year what's going to happen, even with the ACO and so budgets become new forecasts. And so, you know, I like the project. I think it's good to look at it, but I think we need to be open to are we going through hoops to try to change something and will it really have a better outcome at the end of the day? So, I think there's really, you know, all the parties have to say and us being open to that. And if there's a movement to say, you know, and I see that really most of this, I think has to come from the hospitals if we're moving their dates, right? And if they're like, absolutely, we've got to tie out to where the ACO is. I'm not sure they're going to say they need to tie out to the insurance company piece, but you know, let's listen to what they have to say. And to see where we go from there. But, you know, I appreciate all the hard work that you all did to pull this together and really thoughtful to look at the different options. So, thanks. And let me, if I can amplify that a little bit and give a little more context. I mean, I think Tom, to your point, the Gordian knot is an important one. And I think when we started this project, I think there was some sense that we can find a solution. We can find a path forward. We can align our regulatory processes better, whether it's through timeline, or whether it's through more standardized measures, or let's really unpack this and think about how we can, we can do our regulatory jobs better. And a lot of paths were pursued and it seemed like there was some obstacle, whether it was data availability or partner, you know, statutory guidelines or this or that. So what I just want to throw out there is these are just some talking points. We really, really do welcome feedback and we welcome other ideas. If there is something that we've missed in our analysis that, you know, hospitals or insurance carriers or the ACO or other regulatory, regulated entities see as a path forward to streamline our processes, we welcome it. That's the point of a white paper and discussion. And again, I want to echo your point, Maureen, really at the end of the day, we have to make sure that the costs are not outweighing the benefits, right? So that the costs of the administrative costs of changing systems, changing fiscal years at even our own internal costs of piling on too many regulatory processes at the same time, the staff burden of that and the board burden of that, we have to recognize that. So to weigh those costs against what are the benefits of changing some, you know, timeline. So again, I just want to echo, this is an interesting project. I thought it would be easier. I found, we've, you know, we all found more obstacles as we've tried to pursue different paths and put that timeline together. It was like, wow. And all the obstacles within the timeline and realize there's not a lot of movement. But again, so welcome to suggestions. Welcome to feedback. These are just ideas, talking points are throwing them out there. We absolutely need, you know, feedback from all the entities that might be affected. So that's what the point of this is should be win-win for everybody. Yeah. And I'll just ask that one of the things that we did not do here was include the kind of no change option. But that was definitely, you know, as Jeff and Robin and I worked through this, you know, no change or returning to kind of the baseline. It's definitely, it is definitely on our mind. So I think the big question is like, you know, is it worth, is it worth the effort? And as you say, there's, we know that it would be a significant burden on regulated entities and a significant burden on the board to change our processes and to ask the members to do these things potentially simultaneously if we went with a, you know, January first hospital fiscal year. We know that that is a stretch for all parties. So we would want to make very sure that it is worth it. So no change is absolutely an option. And after we share more feedback from stakeholders in the response to the slide paper, depending on how, you know, how that goes, assuming we pursue broader stakeholder engagement, I think we'll, we'll be able to step out whether, whether there would be major benefits or not. But that's, that's absolutely an open question. Other board comments or questions? If not, I'm going to open it up to the public for comments or questions. Go ahead. That was a good presentation, by the way. I would say that's as fast as I've ever heard Sarah talk and it was pretty much at the speed of light. Wow. For something so condensed, she really was fluent and went right through it. Well done. I'm curious. How does this align with the federal government and things over there that are connected in this and what about the legislature? I mean, to Jessica's point, there's an awful lot in here. And that's why I've always heard is that this isn't as flexible as you may think. I actually, I've heard that mentioned quite often within the committees in the legislature. But yeah, how does any comment, how does this align with the legislature and requirements on the federal end? Sarah, do you want me to jump in on that? This is Robin or would you like to go for it? Thanks, Dale. I think in terms of the federal issues, we accepted the federal issues as constraints that we really had limited ability to shift unless there was a, unless it was something like where it was clear that we had a lever. But we did look at the federal requirements because we need to really understand that in order to understand where we have flexibility. In terms of the legislature, I think at least the way that I was thinking about it and I don't want to put words in Jess's mouth or Sarah's, but that first we needed to try and figure out what might make sense, whether that's status quo or some sort of a change. And then if after engaging with stakeholders, we determined there was a change that made sense that it would be at that point where we could engage with the legislature on that change. Certainly in terms of the first white paper, we're hoping that it will be a document that more technical audiences are able to use to better understand both the regulatory process that they're engaged in as well as other parts of the system. And that would include the legislature. Wow. With a number of studies they order and you got a lot of competition to get it just read. It could be top of the line. Anyways, you know what I mean. Thank you very much. Yes, I do. Thank you, Dale. Other public comment? Hi, Kevin. This is Mark. Can you hear me? We can, Mark. Wow. That's a lot to take in. You know, Sarah, I do have to echo for a very complicated thing there. You narrowed it down as well as skinnies. I think anyone could and, you know, still stay on task. So very nice job. I think the only thing that I would throw out there, obviously there's a lot here and there's a lot of conversation like everyone said to have. But you know, I just kind of throw out here that all of this should be done on how do we help inform or manage our total cost of care at the same time that we keep local access to services. So, you know, I know there's a lot going on, but you know, all of this is attempted to inform each other. And this is complicated, boy. I mean, it's unfortunate there isn't an easy button on this one. There just isn't. It would certainly make it a lot simpler, I think for everyone. But anyways, I just wanted to throw that out there. I mean, all of this should be done that is wrapped around of how do we manage the total cost of care and how do we keep services local. Other public comment. Hearing none, Sarah, just like Aaron, Judge did quick and fast last night, you did a great job of hitting it out of the park. Thanks very much, Kevin. Honor about a comparison. Is there any old business to come before the board? Is there any new business to come before the board? Is there a motion to adjourn? Second. It's been moved and seconded to adjourn. All those in favor signify by saying aye. Aye. Aye. Those opposed signify by saying nay. Thank you everyone and have a really great day.