 Good afternoon and welcome everyone. Let the record show that we have all members of the board present and at this time there are four members while we wait a new appointment. So I see that Jess, Robin and Tom are on so we're all present. So I'm going to convene this meeting and the first item on the agenda is the executive director's report and I'll turn it over to Susan Barrett. Susan. Thank you, Mr. Chair. I have a few announcements. First, I wanted to let everyone know that the board received One Care Vermont's FY22 budget earlier this month on October 1st and the 2022 certification form on August 30th, 2021. One Care will present their budget at a public board meeting on November 10th, 2021. And the Green Mountain Care Board staff will present their analysis on that budget on December 8th. So in order to have public comment received and incorporated into that staff analysis, we're asking the public to comment by December 1st and that presentation, as I said, will be on December 8th. I also wanted to announce that we have ongoing public comment regarding a potential next agreement. I'll pay our model agreement with the federal government with CMMI. We've been asking for a public comment since February of this year and any of the comments we receive, we share with our partners at AHS and the governor's office as they are leading the negotiations on a potential next agreement. I also wanna make sure folks see our press release for the meetings for the rest of this month. Just to note, we are convening a meeting on Friday, October 15th. That's going to start at 10 a.m. And that is on the presentation by the board's prescription drug advisory group. And so note that on your calendar, please. And again, it starts at 10 a.m. And then another meeting and something to note is that on October 20th, next Wednesday, we'll have a review of the draft Vermont Healthcare Workforce Development Strategic Plan from Ina Vakas, the director of healthcare reform at AHS. We do have a primary care advisory group on October 20th that evening. And then we also have our general advisory group on October 25th. That's from two to four. The primary care advisory group is from five to seven. And then the last Wednesday of this month, we'll be having an all day meeting. We're gonna start our meeting starting at 11 a.m. in the morning. We'll have a presentation on hospital payment and cost coverage variation from HMA Burns. And then in the afternoon, we'll be hearing about Vermont Hospital Quality Review and capacity planning in preparation for value based care. Again, that starts at 130 as a reminder. And that is from a Berkeley research group. So please look at our calendar. We have a lot of events happening this month and a couple of meetings that are not the typical Wednesday afternoon starting at one. So I'll turn it back to you, Mr. Chair. Thank you so much. The next item on the agenda are the minutes for approval. And I just want to check with Abigail because I think that there might be a mistake on the date of the minutes for the Brattleboro Reconsideration. I don't think that was a Monday, but I could be wrong. Let me take a look. Okay. So I'm going to push the minutes discussion off till later in the meeting. And at this point, we're going to move to the Green Mountain Care Board draft 2022-23 analytics plan. And I'm going to turn it over to Sarah Lindbergh. Sarah? Sarah? Are you able to see my screen? We can. All right, fantastic. Well, good afternoon. My name is Sarah Lindbergh. I am the ostensible leader of the data and analytical team for the Green Mountain Care Board. And I'm here to present our reporting and research report priorities for 2022 and 2023. So as a reminder, if you haven't taken a look at our statute in a while, it's always quite daunting. We have a lot of duties under our auspices. So I pulled this out from 18VSA 9410 to let you all know what I'm thinking of when I think about framing our duties as a data team. So we must maintain this healthcare database and it's got two major components. One is our all-payer claims database, V-Cures. And the other is the hospital discharge data set which we call VUDS. And these together are designed to help the board complete some of its duties which include determining capacity and distribution of existing resources, identifying healthcare needs and informing healthcare policy, evaluating the effectiveness of intervention programs on improving patient outcomes, comparing costs between various treatment settings and approaches, providing information to consumers and purchasers of healthcare as well as improving the quality and affordability of patient healthcare and healthcare coverage. In addition to these duties, we also are required to make that data available as a resource to interested people throughout the state and beyond so that they may continuously review healthcare utilization expenditures and performance in Vermont. So maybe this is the old DFR on me but I always like to start with my statutory charge when I think about these things. So in addition to our duties, we do strive to produce timely and relevant information to support the work that you're all doing and partner with colleagues across the state in their efforts to reach the same ends. But we also have other hats that we have to wear in addition to this support and that includes stewardship of our data resources which also means that we support the Data Governance Council which is an organization that is an offshoot of the board that helps us with those obligations. And we also have a lot of administrative and management duties such as maintaining contracts and data use agreements with people who are providing the data to us. And we also offer support to other data users who are using the healthcare database so that we can get the data out there to have it fulfill its destiny. And also I find that the best way to improve data is to have people use it. And so facilitating its use really helps us with that. So to review the analytic plan that we're getting ready to sunset at the end of 2021, there are essentially three main domains that we focused on, expanding utility quality and the ease of use of our data resources, patient care and regulatory integration. So in that first domain, there were two main focus areas. One was improving data products available to users. And under that bucket, we were able to complete a RFP that helped informed us on specifications for building data sets that are more ready to use for people. So for instance, if you are doing a fiscal analysis for the legislature, you need the data package in a much different way than say someone who's interested in population health outcomes. So getting some basic rules around building those data sets is complete. We also deployed some new business intelligence tools and data marts within the vCure secure environment. So that is pre-packaged data that is ready for users to use and includes some tableau visualizations for authorized users. We did postpone our solicitation of voluntary submissions to vCures. The reason that has been postponed is that there has been some movement on the federal front. That's hard to say fast. Wherein there's a workforce or a task force that was convened to help inform the federal department of labor of how to guide ERISA groups in this effort. So we don't wanna risk any redundant works. So we're waiting till those guidelines are released before we pick that work back up. So that initially was interrupted by the pandemic. We were right in the middle of that effort when that people's priorities understandably shifted. So that's just temporarily postponed. We're also in the process of expanding the discharge data. So according to some additional statutory obligations that I didn't review, we now will be including ambulatory surgical centers in that data set. We are also hoping to add the Vermont Psychiatric Care Hospital in the coming biennium. And data linkage is an ongoing process. The Data Governance Council approved a new policy to help us administer appropriate data linkage within the constraints passed down to us. And so that's in place and there's some exciting projects underway. The cancer registry at the Vermont Department of Health has been linked to the claims data to look at some disparities and detection of cancer, particularly for those living in rural communities. So we're really excited to see some of the work that comes out of that project. The other focus area under the first domain is improving the quality and ease of use of our data resources. So one project that we're still underway is our Enhanced Data Validation Project and analyzing the available data sets. So that means trying to see how well we can coordinate vCures and VUDs and actually doing a financial look from both the provider and payer standpoint of how the data in vCures matches their records. So that's underway and should be completed in the near future. We also completed a data course for board members and we will be renewing that. That's gonna be something that happens every couple of years. So we'll be doing that again in 2022. Yeah, and so then under the patient care and understanding access and cost to care focus area, we released two new dashboards, a patient migration analysis that shows where Vermont residents are going to get their care and a patient origin analysis, which helps us understand where patients are coming from who are seen at Vermont's hospitals. We also have been supporting the APM reporting. That's an ongoing obligation of ours. And then we also have a reimbursement variation project underway. So that is a statutory requirement that will be published publicly in February. So we're gonna start releasing some drafts of that in the coming couple of months. So that is on track. And then we have kind of postponed the decomposition study. We had a pretty good start on it, but given some feedback, we were getting from board members and some staffing constraints. We would like to make sure that before we go further with that, it's truly integrated in the regulatory process. So that's a good segue to that last domain regulatory integration. So integrating regulatory decision-making using data, we were gonna do some proof of concepts related to healthcare utilization and cost for Vermonters, but we postponed that for some other work that will be forthcoming later this month related to these topics. And we'll probably be turning our attention back to extending that work after that's released. And then the last bucket of work is always ongoing and that's the health resource allocation plan. So we were able to gather some inventories and publish some of those on our website. We're now turning our attention to ways to refresh the data, which is also contingent on some constraints with our partners at the Vermont Department of Health. They understandably have other priorities at the moment. We've produced some new data visualizations related to this, particularly around access. And we also have started to do some capacity and utilization research and are trying to incorporate some of those findings in board's regulatory work. So that's, and COVID, so it's been a busy couple of years, I'll have to say. So when we were thinking about the next two years of work, we had two organizing questions and that is how can our team better provide better information to support the board and its duties and knowing that there are so many interesting and valuable questions ahead of us, where should our focus be? And so with the help of the Data Governance Council to focus some projects, the board members laid out some key priorities. One is that they felt like there could be more support from our team in the actual regulatory cycles. So some of our past work felt a little disconnected from the board decision process and that we really had some room to grow in terms of translating the data into actionable information from the board's perspective. Timeliness was definitely a theme of frustration and shouts out to the financial team. A lot of the information that they've been producing has been really helpful and seems really integrated in the board's decision making. So they offered that as an example of something to strive to you. And finally, as always, there's just needs to be more understanding of reimbursement and cost variation, both for care delivered to Vermonters and the care deletes delivered in our state so that we can better kind of give background to the important decisions that the board faces. So we have three main domains for the next two years. Regulatory integration is a repeat, which I think it should be. And the main kind of operational tasks we have in this domain are making sure that each regulatory process has a team member or members assigned to directly work with our staff experts who are the real content experts for the regulatory cycle so that we can fold in existing work more directly and help in future development of reports or other information that might help with their processes and also in crafting new metrics or tools that would really directly be incorporated in the regulatory process. As far as data timeliness, we have a few objectives to improve that. We are actively working on producing quarterly extracts of the hospital discharge data. So that would be kind of non-final subject to change but at least more timely than the current annual release of that data. And longer term, we're gonna be thinking through ways to further accelerate that stream of information. We're also looking at ways to get our claims data in faster and Medicare tends to be the biggest challenge there. So there are some options that we can continue to evaluate to help make the claims data a little bit more timely. And then more infrastructurally, we're looking at our data architecture and policies and procedures so that we can produce things on a more timely basis and have things in place for automation and whatnot. And another important domain is the data quality and utility one where we are gonna try to think about ways that we can simplify and focus some of the data collected from people submitting information so that it can be even more valid and even more reliable and reduce burden on our submitters. And also think of ways that we can adapt our data to account for some of the new payment models that we're seeing in our delivery system. Assuming that we're able to successfully get through our rule revision, which I anticipate we will, we will next turn our attention to the V-tier submission guide. Many of those principles that I just mentioned would be part of that process, but it's been over a decade since those data elements have been visited, so it's overdue. And we'll be thinking about other options to leverage such as some of the new reporting required for federal interoperability requirements. There's also a universal submission data set that we might want to think about leveraging that will involve a lot of outreach with stakeholders to make sure that we can make that as painless as possible. We also are always looking for ways to enhance and extend our data. And here we want to help better support efforts at measuring and addressing issues related to equity in the healthcare delivery system. So we will be as part of that data submission guide trying to get race and ethnicity as required elements in the all payer claims database. And also kind of working with partners to make sure that those data are collected in a uniform way. And finally data integration is kind of the big overarching goal I think across the state. So thinking of ways that we can bring data together in a safe way that protects privacy concerns. So that is what we're planning to tackle over the next couple of years. So I guess I'm here to address any questions you might have. Thank you so much, Sarah. I'll open it up to board members for questions of Sarah. I don't have any questions, Sarah. I just want to thank you for this thoughtful presentation. And I'm really excited about, you know, the initiatives that you're embarking on and how it's going to be helpful to our regulatory process. So it's just a big thank you. Thank you. Hi, yeah. Hi, Sarah. I'd like to, I'm getting some feedback here to add to that. I think it would be helpful at some point in time to just make sure that we've kind of covered the landscape of requests, both from board members and from say our directors, sectional directors so that we know kind of what's moving forward and what's not. Like for me, for example, obviously price and transparency has always been a big issue for me. And that's faked in here. I can see that. But something that's not faked in is how we use our data in the context of the re-examination and reconstruction of the Vermont's QHP benchmark plan, which is going to be happening in the near term in the coming months. And statutorily, given what the legislature passed, we're kind of on the hook for participating in that. And so, you know, for me kind of looking at the QHP population, which is one that we, you know, regulate both in terms of rates, premiums, et cetera, and have some review of their co-pays and deductibles. But that plan was crafted back in 2013 before all the healthcare reform effort in Vermont got off the landing strip. And so, it would be helpful to kind of look at where we've been or where we are with that in order to end, and the legislature is five or six new items that they want to add as benefits, which are certainly going to be costly. And there are some benefits like that don't exist there, for example, like pre-diabetes, which is one of our big chronic diseases. So, you know, I mean, whether we do it or not, I would just like to know, you know, that we're going to do it or not. But I do think that we can be very helpful in an area where we have powerful regulatory authority in terms of the QHP policies and plans and can be in a position to advise DEVA and DFR and the legislation, some of our other partners, as to where we are, how we're following the money now, how we're spending the money now, and how adjustments might be made that make that benchmark plan the best it can be. But I'm really impressed with the work that you've done. It's always been good quality and looking forward to the next couple of years. Okay, any other questions or comments from board members? I don't have any questions or comments, but I just want to also echo thanks, Sarah, to you and the team for all your hard work. And Sarah, is the open position currently posted? Yes. It might be a good time now to plug that there's a position open and maybe some people that are at this meeting can share it out to their network. Yeah, so we're hiring for another analyst on the team, hoping with someone with a data science background to help with some of that automation and integration work that I mentioned. So it's on our website. If you have any questions, please don't hesitate to reach out. Thanks, Sarah. So at this point, I'm going to turn it over for public comment on the presentation about our 2022-23 analytics plan. Does any member of the public wish to comment at this time? Sam Paich, Sam. Hi, everyone. This is Sam at the HCA. I just, just two quick comments. I just want to thank Sarah for all the work on this and the team and particularly the focus on integrating race ethnicity data that gets incredibly important. And I think we'll have major implications for doing racial disparities analyses, which are important to think for everyone in the state. And also to say that, I mean, I saw on the recently graduated graduate school, I'm happy to forward the position to friends that are still in that orbit looking for jobs. So happy to do that. Thank you. Sarah, is there a way that we could post a link to the job posting into the chat for this meeting? I can send the chat off to these meetings, don't I? No. What's that? You're right, you're right. Oh, right. You're right. But you can find it on our website. Yeah, yeah. If you have any trouble finding it, let me know. Okay, next I'm going to turn to Walter Carpenter and Walter, we've been hearing reports from your neck of the woods at the foliage was spectacular this year. I'll send you some pictures, Kevin. It was wild being out there. It didn't happen until late due to global warming, I think. And it's still going on, but we had people from all over the world there, Africa, Europe, Asia, the Middle East, everywhere. I felt like I was in part of the United Nations, but I'll send some pictures to Christine to pass around. That would be great. It's good to hear that Mother Nature is creating a beautiful landscape for tourists from all over the world to come to. It's incredible. And people come to Vermont because it is such an enigma on the national scene. And as one person from the South said to me, why aren't they putting shopping malls all over here? Like they're doing down south and everything. It's kind of phenomenal when you talk to people from all over the country about the state, the foliage, all the rest of it. And here we have a state in America that is all of a sudden is beautiful and is not trying to waste itself to commercialism. It's really in something. It's coming incredulous in a way. And then you have people from China, India, Pakistan, Britain, France asking me about this and that about Vermont and about why is it so different than the USA as a whole? And it's kind of interesting to try to explain that. You know, we have a Green Mountain Care Board, for example, which is the only one of its kind in the nation to my knowledge. We were the first to do the marriage thing with civil unions and that's hard for so many people to grasp. But my question here is great on the data and I know it involved a whole lot of difficult work just as difficult as it is to be in a tourist business at times. And I just want to know what the state is going to do for the general public in regard to access or how it will help that. And I will send those pictures to Christine. Yeah, so I think that the other we're experimenting with ways that we can provide information that's helpful across the spectrum. And yeah, you know, V-Cures is being used to help answer a lot of questions across the state. And I know I expect that it'll be one of the resources that's tapped in looking at the state's investigation into wait times and that access issue. But yeah, I guess. So Walter, just to follow up on that, we have been accessing the two databases in the sustainability planning, which does provide information that can be translated into access questions as well. And we've also been forwarding information to the group that is working on access. And Jess, maybe you could talk a little bit about how you might envision information in the databases as being useful to that. Sure, so I think what we're gonna, the databases are really helpful for a historical view because you can certainly use claims data and discharge data to look at utilization over time. I think what we're trying to figure out right now is how to get point in time data on access right now. So the claims databases aren't as helpful in that regard. So we're trying to identify what are the benchmarks for how we wanna think about access. What are the right questions that we need to ask? And I think we're gonna be initiating some surveys potentially to try and gather some information from providers. So I think the issue largely with the claims databases is that they're a look back, right? And we're trying to understand a look ahead and that the current landscape for access. So that's one of the drawbacks of the databases that we have, those two databases. But they'll be helpful in trying to understand utilization over time. Yeah, that's the key. We'll have something to compare what the new information brings in to. And that's gonna, Walter, it's the most frustrating thing in the world when we as the board are making decisions and we're looking at information that's two years old. And I think that each one of us gets frustrated at times, but it's the nature of the claims run out and it's the nature of the world that we live in. And that's something that we've been trying to accelerate, but we're nowhere near a point in time where we're even close to having something that has instantaneous information. Now I would just say statewide, there's efforts where we're trying to make claims and clinical information work together a little bit better. Because that's something that as a patient might actually be really helpful. So, for instance, your doctor might be able to know if a prescription was filled and like, oh, did you remember you had that prescription? Stuff like that. Okay, is there other public comment? If not, Sarah, I wanna thank you for a great presentation and hopefully you'll get lots of great applicants because I know that your team could use the help because we're tasking you to do an awful lot. And so thank you very much for everything that you do for the people of Vermont. Yeah, and I would say that the members of the team are the ones that really deserve the thanks. So I'm fortunate to work with such a great group and thank you for your time. Okay, so I understand from Abigail that the minutes should have said Wednesday, September 15th and if somebody would like to make a motion if they could in that motion correct the minutes to reflect that the 15th meeting was on a Wednesday, would someone like to make a motion? Sure, I'll move that we approve, hold on, I just need to... It's the minutes of Monday, September 13th and Wednesday, September 15th, if that's helpful. Okay, that is exactly what I was looking for. I move that we approve the minutes of Monday, September 13th and the minutes of Wednesday, September 15th with a correction to indicate that the 15th was a Wednesday. Is there a second? Second. It's been moved and seconded to approve the minutes as corrected. Is there any further discussion? Hearing none, all those in favor of the motion please signify by saying aye. Aye. Any opposed? Let the record show that that was passed unanimously. So now we're gonna turn our attention to a discussion of the 2022 budget guidance and reporting requirements for Medicare only non-certified accountable care organizations. That's a mouthful and I'm gonna turn it over to Russ McCracken, Russ. Yeah, thank you, Mr. Chair. I'm gonna share my screen here. All right, can you see my screen? We can, yes. All right, great, thank you. So I'm presenting for the board to start discussion and consideration for guidance and reporting requirements for Medicare only non-certified ACOs for 2022. It's the first time that the board has had guidance for this type of ACO. I'd like to start with a quick framing of this under the statute. A Medicare only ACO is not required to be certified by the board under statute. 18 BSA 9382 requires certification for ACOs that receive Medicaid or commercial insurance payments, not Medicare only. However, a Medicare only ACO is still subject to the annual budget review and approval in 18 BSA 9382 B2, which tells the board to adopt rules for reviewing and approving the budgets of ACOs divided between those that have more than 10,000 attributed lives in Vermont and those that have fewer than 10,000 attributed lives. The board's applicable rule here is rule 5.405 and it says in deciding whether to approve or modify the proposed budget of an ACO that will have 10,000 attributed lives or fewer than 10,000 attributed lives. Jesus, great. It takes into consideration benchmarks established under 5402 criteria set out in the statute that the board deems appropriate to the ACO's size and scope. Elements of the ACO's payer specific programs that are applicable to the all payer model and any other issues at the discretion of the board. So with that context, what we've done here is prepared a draft guidance that is more streamlined and appropriate in size than what the board looks at for one care of Vermont, which has significantly more attributed lives in the state. I also wanted to note in the rule in 5404, calls for the board to have a public hearing and review of the ACO's budget, except that the board may decline to hold a hearing concerning a proposed budget for an ACO that has fewer than 10,000 attributed lives in Vermont. And I just flagged that now as something for a little bit of consideration and discussion as we go through the actual draft guidance. So the scope of this guidance is fairly limited. It's for an ACO that's not certified by the board, participates only in Medicare, not Medicaid or commercial payers and has fewer than 10,000 attributed lives in the state. Currently, there is only one ACO that fits this requirement, which is a direct contracting entity managed by Clover Health. And I'll talk about the procedural background here as a reminder in just a minute. But the guidance is set up in a generic way that would apply to any ACO meeting these criteria. And I think I did note for the board that there are, there is another potential new entrant, but at the moment, there's only one ACO for which this guidance would apply. So the procedural background just to refresh everyone's memory, Clover Health requested a waiver from the board for rule 5.4, which was the budget review and 5.5, which is monitoring and oversight. Clover Health was in to a board meeting over the summer, early summer and or late spring and made a presentation, requested a waiver. The board deliberated and declined the waiver request and asked staff to prepare a budget guidance and process working with Clover and the HCA. So the draft that you're seeing today has been prepared by legal and policy staff. Both the HCA and Clover Health have reviewed and commented on it. We've had calls with both Clover Health representatives and the HCA to discuss the draft and understand their comments and their feedback. And so with that, I'd like to switch over and actually go through the guidance itself. All right, and hopefully I'm still presenting. You are. Great, I won't, I'll go through the guidance. I don't wanna read every question in the guidance, but if there are clarifications or comments specific to any section, I'm happy to take those as we go through or address them at the end. So I'll start here. The background sets out roughly what I've just gone through in terms of the scope of this guidance. We also have a timeline here. You'll see that the dates are still bracketed to be finalized based on the board's review and approval here. And then I also wanted to note that going forward in future years, our intent would be to align these dates with the dates that we have received review and the board approves are just one care for months budget so that they would be on the same cycle. I think we received a comment from Clover Health and I think we acknowledged that the date and the timing is always a bit of a challenge in terms of how the ACO finalizes its plans for the coming year to have something that they could submit in response to a budget review and then have the board review and actually approve it. But our intent is to have the dates aligned with the one care Vermont process. Introductory, largely tracking what we have in our rule, the ACO can request confidential treatment for anything that it submits and that request would be dealt with according to the Vermont Public Records Act. Also note here that recognizing that Medicare only ACOs are participants in Medicare programs, we think it's appropriate to allow an ACO to respond to some of the questions here to the extent they can by reference to a participation agreement with Medicare or a specific requirement, programmatic requirement of whatever Medicare model they're participating in. And that sort of runs through the whole guidance. So we collect some basic information about the ACO, its background, governing documents for the ACO and questions about the ACO's executive leadership team. But you get some specific comments from the healthcare advocate that we've incorporated throughout and I might not note all of them, but I will note to hear the inclusion of a conflict of interest policy for the governing body and any ACO compensation structure that's tied to a performance that might reduce the amount paid for patient care. Next we ask about material pending legal actions against the ACO or its affiliates, against its executive leadership team related to their duties or any actions known to be contemplated by government authorities. Similarly, questions going to the character of the ACO, whether it's leadership team or board members are subject to legal action or findings indicating wrongful action. We ask if the ACO has any other accreditations and ask them to provide that. The next section broadly addresses the ACO's provider network. So for each ACO and there is an appendix that accompanies this, but it largely tracks the questions that you're seeing here. As the ACO to provide the name of their providers, provider type, the payment model that they have with that provider participates in, whether they have specialty providers and whether they know for a provider what percent of that patient population is going to be attributed to the ACO. As for a brief narrative summary of each contract type and payment model that the ACO uses for providers, and then a couple of questions here. If the ACO has providers that are assuming a downside risk, we ask them ACO to describe that contract with the provider, what percentage of the downside risk the provider is taking, whether that downside risk is capped, what the mitigation, whether they're requirements for the provider to mitigate that risk. The concern here would be what risk there is, if any of the providers are taking on or being exposed to a risk that might jeopardize their solvency or their ability to fully function under the ACO model. We ask for a template of the provider's contracts, ask them to describe any referral programs that the ACO uses, and then ask them to describe their network development strategy, how, if they intend to bring new providers in Vermont into the ACO, how they might do that, whether there's a difference between an independent versus a hospital-owned practice in that strategy, and then if there are certain types of providers. Russell. The next question. I'm sorry, go ahead. I either lost you or you just stopped talking for a little bit. I'm sorry, am I back on now? Yep. Okay, I got a bad network quality message. It's just unusual. Okay, moving on to the ACO's payer programs, our expectation, I think, is that a lot of these questions could be addressed by reference to, say, a direct contracting entity's participation agreement with Medicare, recognizing that this is generic guidance. We are asking the questions here and asking the ACO to provide a response to it. But as you'll see, the first question is asking for a copy of the participation agreement or other relevant agreement with CMS governing the ACO's involvement with the applicable program. And we ask, we have another appendix here, but it again tracks, I think, these items, asking for attributed lives, attribution methodology, projected spending or payments that the ACO expects for those attributed lives, any benefit enhancements under the CMS program that the ACO intends to participate in. Ask them to describe their risk sharing agreement with CMS, whether it's a full risk, a 50% risk if it's something else, whether there's a minimum savings rate, minimum loss rate or other similar concept. Whether that risk corridor is capped, what the risk mitigation provisions might be in their agreement and what's the method that CMS uses for setting the budget target. A couple of further questions related to that point, I think categories of services included for determining the ACO's savings or loss. And then describing the ACO's benchmark or their capitation payment. As for the list of quality measures that CMS might use to determine the risk sharing payment or the payment under the applicable program, and then the methodology for beneficiary member alignment. Following that, we go to the ACO's budget and financials. We're asking for the most recent audited financials for a publicly traded company that might be information that's publicly filed for another ACO. It's something that we would ask them to submit. In the question that's cut off here at the bottom of the page, we asked the ACO for a narrative, sort of a description of how the money flows between CMS, the ACO, the providers and the patients. And along those lines, it's kind of a description of the ACO's business model. Part of that description would be how the ACO expects to realize savings and some demonstration that the ACO has sufficient funds to support its administrative operations and meet its payment obligations. That's not a Vermont specific question. We do ask if it can be segmented, the dollar values of anticipated payments to Vermont providers. And if it can be segmented, related anticipated savings from that. Next question would be for an ACO, it's taking the risk of loss. Ask them how they would manage that liability if they have losses at 75% of their maximum exposure or the full amount of their maximum exposure. And so that would be what their kind of risk mitigation elements are, whether it's covered by a reserve or whether they use some other reinsurance or other methodology for that. Question five here, I want to note because it's asking specifically for data for 2021 and 2022 as an estimated budget, the amount of fixed payments or shared savings distributed to Vermont participant providers. And then the other questions are on an ACO wide basis, shared savings or loss for the ACO, shared savings that they would invest in infrastructure or other resources like that to providers on an ACO wide basis. The reason the question, I'm sorry, may have cut out again. The reason the questions are set up this way is we recognize that a Medicare only ACO that's operating in multiple states likely doesn't have a Vermont specific budget. And so certain information might not be something we can reasonably ask for on a Vermont basis, but we could get on an ACO wide, and sorry, on an ACO wide basis. Moving on to section five covers, the ACO's model of care. And we asked them to describe their model of care, including a number of elements that are called out here. And we also asked whether their model of care improves performance on a number of specific measures. And these are measures that, sorry, I pulled from the Vermont's all payer, boomer APM, all payer model agreement with CMS. So the idea is to track whether what the ACO is doing aligns with the quality metrics that the state is measuring under our all payer model agreement. And a couple of other questions here, whether the ACO has strategies for expanding capacity in existing primary care. Broadly describing the ACO's population health initiatives and how the ACO might assess the performance and success of those initiatives. And then a copy of the ACO's grievance and complaint process. The last section of the guidance here includes a a chart that we collect specifically in this form from one care of Vermont and it is what we used to determine whether it's a scale target qualifying initiative. So I won't go through that in detail here. So that's a walk through the guidance. Hopefully everyone's still awake. A couple of questions, like I said, we've had some, we had a discussion with Clover Health, we had a discussion with the HCA. If I can kind of broadly summarize those questions and I don't, if I'm not doing it justice, I see Dave is on the screen here and he can correct me for Clover. But I think the kind of the big question here is that we've been asked from Clover is an understanding of how the board intends to use the information that's being collected, understanding what the board might approve or adjust under the broad umbrella of approving or modifying the ACO's budget. So understanding what gets adjusted, recognizing that there are some elements of ACO's operations that are set by CMS requirement and there are some that are kind of broad multi-state aspects of the ACO's budget. And Clover also expressed some concern about the timing that I alluded to at the beginning and what happens for adjustments that are made mid-year. If the ACO is really not able to make those that kind of adjustment mid-year and sort of what other standards or criteria is the board going to apply as a guidance or a benchmark for approval of the budget. And so I know we did speak with Clover about those questions, but I think those are sort of their comments. And I guess with that, I'll stop and turn it back to you, Mr. Chair, for board questions and comments. Thank you very much, Russ. Are there questions or comments from the board? This is Robin. I don't have questions for Russ, but I thought I would just chime in with some thoughts about the questions that he had just raised. For me, I think the Medicare only ACO budget process is a combination of transparency and ensuring that we have transparent information about all ACOs operating in our state, as well as having an understanding of the business model and the care model, in particular, so that we can understand how that particular ACO fits or doesn't fit into the overall direction that the state is headed in. I think it's important for us to understand those factors. I do think that because it's a Medicare ACO program that there's, we'll have to see the information that we get, but there's gonna be, for me, I think the kinds of conditions that we could potentially put on a budget might include certain things around any area that either raise some concerns for Vermonters or where we feel like we need more transparency. That's just, without obviously having reviewed the budget, it's hard to kind of anticipate that in advance, but that's my current thinking on it. I think I like the approach for us where we can allow regulated entities with under 10,000 lives to point to other publicly available materials. I think that's a good way to ensure that we're not being too burdensome, but also ensuring that we can have transparent information to understand how this fits into the bigger picture. Thanks, Robin. Russ, is this draft currently posted on our website? It is, yeah. And what is the earliest date that you would expect the board to have a vote on this? The earliest would be next week. But it doesn't need to be next week. Okay, so it could be the week after, but let's for the purposes of informing the public, ask them for public comment back by next Tuesday. And we can make a judgment call on whether or not it makes sense to defer another week or not. But so just so everyone knows that the draft document is posted to the website and we are taking public comment through next Tuesday at least. We always take public comment whenever it comes in anyways. So with that, Jess or Tom, do you have any comments or questions? I have a couple of quick ones, I think. One, I just wanna make sure I probably could have looked this up myself, but I wanna make sure that the provision that requires the oath to be taken pursuant to 18 VSA 93.74, does that include the penalty as well? Is there a separate reference to the penalty for associate with that oath or? I don't think I have a separate reference. So I mean, I know in the hospitals that we have a oath and if there's a violation of the oath, there are specific amounts that the hospital could be liable for and I'm just wanna make sure that there's a dollar amount or some kind of penalty, explicit penalty tied to associate with that oath. Well, you can look it up and tell me later. I just, it's, or I could look it up, I'd rather have a lawyer look up a penalty rather than me. Yeah, I don't recall if hand I can look it up. I can also see, and it just doesn't come to mind right now whether that's something we put in the oath itself in the form of the oath that the hospital's filled out and signed. But I can look it up and we can include a reference to that somewhere. And so my other question is just how this all might migrate toward fixed prospective payments. As I read this in a number of sections, it talks about fixed prospective payments, but it's kind of asking the ACO applicant to kind of tell us what they expect to happen, how much will be fee for service, how much risk there will be, et cetera, et cetera. And I'm just wondering how we can structure this to maximize in the relationship should wanna occur that these fixed prospective payments be true, fixed prospective payments and leading us to the goal that we want in health care reform that fee for services diminished and fixed prospective payments is enhanced. We know from going to the recent hospital budget process that about 33% of the Medicaid payments in Vermont to hospitals are in some kind of a fixed prospective payment. But I'm just wondering if maybe we could take that HCP land framework to give this some structure. There's those four categories and just make sure that the applicant aligns their presentation with those and that as much as possible in our relationship or in our guidelines emphasize that we're big fans of fixed prospective payments, true fixed prospective payments and not so much fee for service, especially since we're getting into small populations here. So that if there are a number of these ACOs below 10,000, the administrative cost, I would think would be more than the administrative cost associated with a 10,000 attributed life plus ACO. So that's just kind of a thought in the back of my mind that we know where we wanna go, which is fixed prospective payments. And so how do we structure these guidelines to encourage the applicant to head in that direction as well as much as possible? That's more comment than a question. Okay, Jess, do you have any comments or questions? Not at this time. I'm actually looking forward to hearing if there's any public comment on this particular guidance, but I'm okay for now. Thank you. So at this point, I will open it up for public comment. And also I just wanna extend an invitation to both the healthcare advocate and to David Alt if you wish to say anything further at this point, please feel free. So public comment, does anyone wish to speak? So David, I see your hand up. Hi, yes, thank you, Mr. Chairman. First, I just wanna say thank you so much to the board staff in particular to Russ for all the openness and collaboration in working with the stakeholders, obviously including Clover over the past few months as they've assisted you all in carrying out your statutory obligations regarding ACOs. In particular, they've really focused their efforts on trying to balance the need to protect the interests of Vermonters with the significant administrative burden that reporting obligations place on healthcare organizations that are focused on coming into Vermont and improving healthcare in Vermont. So really appreciative of those efforts they've taken that very seriously and really appreciate the engagement of conversation there. So that said, Russ raised a couple of the questions that had been top of mind for us as sort of like a larger threshold matter, two points. One is the one about it would be helpful to have an understanding as much as possible so what are the standards against which our reporting obligations are being judged? Is it a subjective standard? Is it an objective standard? I understand the ultimate goal is transparency to protect the citizens of Vermont and to make sure that the healthcare that Clover or other ACOs are providing in Vermont aligns with the mission and vision of the state of Vermont as a whole. So totally understand that but to be able to drill down a little bit more and be able to have some better sense if for no other reason than to help ACOs, to help guide ACOs that are in Vermont to be providing the kind of care that aligns with what you're looking for for the state. So that's one sort of overarching thought. The other overarching thought is just the idea of, and it ties into the first one, right? The idea of making sure that the reporting obligations are tied to those goals. So one thing that I do think Russ and the team was looking at is as you look at them, trying to think about, all right, if we're reporting on X, Y, or Z, how does that further the goal or the obligation of the board to determine whether the ACO should be operating in the state, right? So just to make sure that each piece of reporting information has a purpose. And while they've done a great job of narrowing it down from some of the broader requirements for the Vermont all payer model, it is still a lot to report even where you can sort of link to some publicly available data or provide a participation agreement. There are still a lot of parts of this document that are onerous and require specific work just to Vermont. And at times are even duplicative. So for instance, the section six is tables to be completed just to match the one care of Vermont's forms. And that's mostly information that's already being reported in section two or in section five. And it's just a task of doing it to make it simpler for the one care Vermont team to see whether they're meeting their obligations to Medicare. And so some of these tasks, I think still do place significant burden on any ACO that's coming into the state. And so one thing I would like to raise for your consideration in this is also something that we've spoken to Ross and Michael and others about is the idea of obviously there's this over 10,000 patient under 10,000 patient threshold for which rules or which reporting requirements apply. But also thinking about the idea about whether there should be some sort of a floor, right? And so if there are ACOs that are very small have a very small footprint in the state. Should there be limited applicability of this guidance such that these onerous reporting obligations kick in only when there's some minimum, a number of beneficiaries some minimum threshold of Medicare beneficiaries in the state of Vermont that are participating as part of the ACO. Again, if it was whatever a number like 100 or 200 patients this ongoing obligation, obviously the weight of that burden becomes larger compared to the size of the patient. So really want to pose that to you all for your consideration. And in fact, in tying it in actually to your statutory mandate when you look at the statutory mandate for the rules that you put in place for ACOs that are under 10,000 beneficiaries. It actually says that it's the rules that you deem appropriate specific to an ACO's size and scope. And so I think that there's a calling there for you to be able to take that kind of consideration into account. And so those were the comments that we wanted to come with. Kevin Murphy from Clover is with us. So he's down in the weeds of the day-to-day operations of Clover. So he's certainly here to answer any questions that you may have or any additional feedback as well. In terms of a couple of things that I just heard I don't want to take too much of your time but on the timeline piece just to elaborate on that a little bit the way it works for ACOs and I don't mean just the direct contracting entities but this is actually true pretty much across the board for all Medicare only ACOs that they have to any individual ACO has to decide where and how it's participating pretty much by the end of August of the year before. So for instance, August of 2021 was when Clover had to make a decision about whether and where it was participating for 2022. And after that time they cannot pull back. So they are going whether they actually operate in the state or operate wherever or not they are responsible for the care of those beneficiaries for the following year. And so I just wanted to point that out because it's something sort of that is unique to the program. And so I thought worth mentioning and that's why we had talked about timeline and how it might make sense. Obviously this year is a different situation because the development of the guidelines for the first time but just in looking at future years and putting that out there for your consideration. And let's see, I think those were my only other points that I wanted to raise. Obviously happy to answer any questions that you have. But remember, Pelham, with respect to your question about fixed prospective payments what I can say about that is that obviously these are Medicare only ACOs and Medicare only ACOs are operating in the fee for service space, right? And so while this is all coming from a background of fee for service, what the ACO models are intended to do and their whole purpose is to get away from fee for service is to get away from paying for volume and instead paying for value. And so the more advanced or progressive of a ACO model or ACO initiative and ACOs is participating in more of those payments are going to be driven to upfront prospective payments to that kind of engagements with providers. So instead of a provider being paid for just seeing as many patients as possible paying the provider for really high value care. And so that is where, and Kevin could speak more too but that's where Clover is and as a direct contracting entity in sort of the most advanced or sophisticated of the ACO initiatives, they are the furthest down the line on that scale or on that track to move away from fee for service. So I'll pause there, but happy to answer any questions. Thank you, David. I'm going to proceed with the public comment and then if the board members wish to ask you questions they can afterwards. So Walter Carpenter. Thanks Kevin. I'm not just a small question, perhaps it related to this presentation. How many of these direct contracting entities are operating in this state right now? Is it just one or is it several or? One that I'm aware of, but then Rush you alluded to the possibility of another. There's just one direct contracting entity operating in Vermont that we're aware of. There's a potential, we were contacted by another potential new entrant but not a direct contracting entity was under a different Medicare program. But that's not operating in the state currently. And is there any way to stop them? Well, they do have to meet the requirements under Act 113 and that's what these rules are, this draft guidance is a result of. I guess what I would say is it's a Medicare program which is a federal program. Is there other public comment? Is there other public comment? Hearing none, do any board members have questions for David or Kevin? For us, do you have anything in addition to add? I'm wondering, I'm trying to think through what the best approach process-wise is for us. And yeah, I think we've, the board has heard some comments from Clover. I don't know if it would be helpful to have some time to reflect on those, to look at the guidance again. I guess what I'm saying is I don't have anything else for this meeting, but. I really heard four things from the board. I heard four things from Clover. One was the standards for reporting, making sure that they're understandable and objective or subjective. Number two, making sure that reporting obligations are tied to the goals. Number three is the timeline question, which is, if there's anything that can be done there, seems to make sense. And number four was a straight exemption for small entities. And I think that if the board had been inclined to go that route, there might have been a different outcome at the hearing over the summer. So I think that one can almost be scratched off the list. But that's what I heard, Russ. Yeah, that's what I heard as well. I think on the threshold question, what one scenario that I agree with what the board addressed earlier in the summer is whether entities below a certain threshold would be not subject to a budget review process. It's also, and I'll just, I just wanted to kind of point out, but it out there is that the board could decline to hold a public hearing for entities below a certain threshold, depending on how the board felt. Yep, and we have that ability to not hold public hearings on hospital budgets as well. So that is a possibility. I'm curious, we haven't heard anything from the healthcare advocate. Is there anything that the healthcare advocate wishes to say at this time? This is, go ahead, Eric, if you're gonna go. Sure, I just, I mean, I think at this, so the board staff has been in contact with various members of the HCA and we found those meetings very productive and we appreciate the input on the guidance and are happy with the collaboration and the compromises reached. Thank you. Thanks, Eric. So Russ, maybe the best thing is to sleep a little bit on the points that were brought up today and perhaps having some additional conversations with the HCA and with Clover and we'll go back at this next week. Hopefully we'll have had a chance to receive some other public comment and really have some time to be able to think about all the language that's in the draft now. But I gotta tell you, Russ, as always, I'm very impressed with the work that you do and very thankful that you're part of the GMCB team. Thank you. Chairman, if I may just say one more thing before we move on. Certainly, Eric. If allowed. Thank you so much. I would just really request that before you scratch off that fourth item regarding a minimum threshold that you do give it some consideration. In that, I think it is different from what was discussed over the summer, early in the summer. Again, the idea being the request for the waiver early in the summer was a request to have no reporting requirements for any ACO up to 10,000 beneficiaries, right? Which is a sizable number of beneficiaries because that's where the statute delineates between large and small. And so I think this is just sort of looking at it another way that now that we see what this guidance is, what the reporting is, if an ACO is working with say one provider in a state, right, and a small number of beneficiaries, if you're actually looking at the purpose and the goals of the reporting, right, are they necessary at that point? Or do they really kick in and become necessary when there is enough of, there are enough Vermonters or enough providers in the state that are engaged that obviously, then the burden warrants obviously the review and that level of reporting. So not to be a dead horse, I just wanted to ask that you please do just give that some consideration before just scratching it off the list. I think we hear you pretty loud and clear. David, let me ask you a follow-up question to what you just said in the current scenario. Are we talking about 20 providers or one because it's one practice? Well, you mean the one that I was throwing out? You could say it either way. So it could be one practice with 20 providers and I don't know, 100 patients or it could be a solo practitioner with one doc and 20 patients. And I probably put both of those on the smaller side as opposed to again, if you have whether it's a practice or individual docs, but if it's a total of say, I don't know, 50 providers and 50 docs or something and they have 4,000, 3,000 beneficiaries, right? And again, this is all Medicare beneficiaries. This isn't patients as a whole, right? I mean, so that's sort of the gradient scale. So I was just pulling one as sort of one out of the air, but I mean, you could think of it as one doc or one practice. Okay, thank you. Board members, any follow-up? I'm good for now, thank you. Okay, it looks like we'll be coming back to this. And again, public comment is open and I strongly encourage anyone with thoughts to send them our way. So with that Russ, I guess you can stop sharing your screen and we'll move to the old business portion of the agenda. Is there any old business to come before the board? Hearing none, is there any new business to come before the board? Hearing none, is there a motion to adjourn? So moved. Second. It's been moved and seconded to adjourn. All those in favor of the motion signify by saying aye. Aye. Okay. Any opposed, signify by saying nay. Thank you everyone and have a great rest of the day.