 I think she's coming pair foster for the. Vitalize hearing great right call to order the green mountain care boards hearing of November 15. Today we have. 2 agenda items the health information exchange strategic plan, which will be presented by. Director of health systems data and analytics, Kate O'Neill, and we'll hear from Kristen McClure from the agency of human services. And then we have the vitalize health 9 ACO budget. First, I'll turn to director Susan Barrett for her executive director's report. Thank you, our faster. I first want to remind everyone that we are in the midst of a community engagement project per act 1.67. We're actually. Last week of work, the information to access these virtual community meetings is located on our website. So I'd encourage folks to. Take a look at them and if you can join in this last week, please do. I want to show you who have attended these sessions so far. The rest of us and their input into the current state of Vermont's healthcare system is going to help us immensely as we work through the act 1.67 hospital sustainability work. So, again, thank you to all those who have attended. And if you haven't, please try to get on a meeting this last week. We're also accepting public comments regarding this work and there is a portal on our website as well to submit those comments. And we'll continue to accept those after this week. I also just reminder, there's several open public comment periods for several that we are at right now. And then our regarding a potential next model with and we are accepting public comments regarding that potential work. The agency of human services is completing the work on a next potential model and the current model. So we share any of those comments and partners at the agency of human services. And then I just want to wish everyone a happy Thanksgiving next week. We do not have a board meeting on next Wednesday. Happy Thanksgiving to all of you. And with that, I'll turn it back to you, Mr. Chair. Great. Thank you. I'll just turn it over to miss O'Neill and to introduce our speakers and welcome, Ms. McClure and Ms. Jaquette from Vital. Thank you very much, Chair Foster. Hopefully you can hear and see me okay. And I'm going to share my screen. I will provide a very brief sort of process update for all of you. And then I'll turn it over to Kristen McClure at AHS who will present on the HIE plan, which was submitted on November 1st to you for your review. And then following that, Christina Choket from Vital will walk through the connectivity criteria, which is also a review before you, before the board. So I'm going to share my screen. Just a couple of slides for you as a process update. So yes, I'm the director of health systems data and analytics here at the Green Mountain Care Board. And I'm just going to go through the statutory authority, a bit of the review process, and then we'll get into the presentation. So state statute established that establishes the HIE plan outlines a variety of features that the HIE plan must address or include implementation of electronic health information infrastructure, standards and protocols to promote patient education, patient privacy, physician best practice, and the like. And AHS is required to revise the HIE plan annually. So last year was the five year comprehensive plan submission. And today, they will present the annual update to that plan. And in terms of Green Mountain Care Board oversight of the plan, the board is charged with reviewing Vermont's statewide HIE plan. You will see it referenced as the HIT plan. It was previously known as that, the health information technology plan, but it's referred to these days as the health information exchange plan. And the board's authority is focused on whether or not the plan will support achieving the principles for health care reform. Sorry. And then the board is also required to review the connectivity criteria for providers connecting to the Vermont health information exchange or the VHIE. And vital as the agency that runs the VHIE is required to present that criteria for approval by you annually. And they need to do that before March 1st of each year, but since quite a few years, we've been reviewing the criteria for the coming year in conjunction with your review of the HIE plan. And so we're doing the same thing today. So just a quick timeline and process reminder. AHS submitted the plan to the board earlier this month on November 1st. We're currently in the middle of a special public comment period, and that will end on December 4th. And then following public comment, we'll have, we'll come back to the board with staff recommendation and potential votes. So that will happen December 6th or 13th. And I don't believe that that is yet finalized, but we'll, we'll get that finalized soon. And then so you will vote in December on both the HIE plan as well as the connectivity criteria. So to support the board's review of the HIE plan and the connectivity criteria, a few years ago staff proposed principles or review questions. And so for the HIE plan review, these are the four questions and essentially the first principles one and two are does it align with statute. And then whether the HIE plan meets the goals of other recent legislation and whether the HIE plan incorporates national best practice and stakeholder input. So with regard to the first review principle is the HIE plan consistent with the HIE plan requirements. 18VSA 9351, I just am putting on the screen for you here the eight plan requirements. So essentially it's about supporting statewide use of the VHIE education for the public and healthcare professionals incorporating national standards, making strategic investments, funding integration and data ownership, data governance and confidentiality, confidentiality, security of patient information. And then for the connectivity criteria review, we developed these two questions or principles for your annual review which focus on alignment with the HIE plan goals and clarity of the criteria themselves. They're really an operational tool. So are the connectivity criteria sufficiently clear to be operationalized by vital? So that's it for me just to wrap up my part here again. We're in a special public comment period open through December 4th and we'll return to the board in December to vote on both the plan and connectivity criteria. So I'm going to stop sharing my screen and then Kristen, if you're ready, I'll turn it over to you or will you run your own slides or would you like me to? I think we're cute up to have my cash do them Kate. So great to stop sharing. Thank you. And thanks everyone for having me today. I'm Kristen McFloor. I'm the chair of the HIE steering committee and the health data officer at the agency of human services. And I just want to do a quick intro for some team members that we have joining us today. We have Bart Gangler who is our general counsel on the line. And Mahesh has joined us as well. He is one of our outstanding PMs for our HIE. So Mahesh is offered to run the slides. So Mahesh, if you want to bring them up, get one. Sure. Okay, so agenda today will cover the goals of the health information exchange, the steering committee composition components of the HIE health information exchange. Talk about the overall ecosystem around it. We'll touch on our 2023 accomplishments as well as the goals for 2024. So for the next slide, here are four goals for the HIE. They're consistent year to year. Create one health record for each person, better health outcomes, improved health care operations and use data to enable investment and policy decisions. So we're not going to read this slide, but I did want to note here that we have 19 different members of our HIE steering committee. So a really good cross section of the overall health ecosystem in Vermont. There are little stars next to four members. These are new organizations that are part of the HIE steering committee year to year. Three, we're at the request of the Vermont Air Board last year. And then we have one new ad as well from the independent programs. And here's the overview of the four components of the HIE ecosystem. And this is based on national standards and best practices. This is from the from ONC, which is the Office of the National Coordinator for Health IT. It's a mouthful, but it's the ONC framework that they have created for successful HIEs. And it has four components to it, the financing or the funding, policy, governance and technology. And these four components are consistent with how we have framed and we talk through the HIE strategic plan. On the right hand side of the screen, it really expands the core, the center of the technology here. And I think of the right hand side of the screen as the maturity level. So at the very bottom, we have the foundational services, which are for the most part all in place at our HIE that vital operates with the exception of the provider directory. And we'll talk a little more about that. And then as we climb up the ladder, we cover the exchange services. This is really the layer of data collection, normalization, standardization, data quality, interoperability. And then at the top of the maturity ladder, really we have those end user services, some of these more advanced fully mature services. Vital for many years has been doing the reporting services. And you'll see on the 2024 strategic goals, which is consistent with what we had committed last year, really stepping into the analytics layer, as well as care for nation tools. And how should we go to the next slide? So talking about the unified health data space, and we use this interchangeably with the health data utility. Health data utility is an industry standard term to really talk about the ecosystem around HIEs that have evolved from the send received clinical data to a more comprehensive health data utility to share information for authorized users to access that in a meaningful way to gain insights. And I think it's important for us to remember that our HIE is already a health data utility and is already an advanced HIE. And there are two times throughout the year that CMS reached out and noted that Vermont has won the best HIEs in the country, which was certainly a great compliment to hear. And to compare and contrast a little bit for, I'll say like traditional HIEs versus our HIE in Vermont. So typically traditional HIEs don't provide the patient education whereas for our HIE we do. Traditional HIEs often don't provide the public health service that our HIE does. And we certainly noticed and noted how incredibly critical that connection is and was during the pandemic. So a really outstanding testament to the work between public health and our HIE in the public health response. And while we saw reporting services on that top full maturity layer, it's also worth noting not all HIEs provide that either yet for many years vital does provide reporting services to our ACO as well as the blueprint. And I think Mahesh we can go to the next slide. And as Kate had mentioned, one of the items is about reflecting how does the HIE strategic plan support healthcare reform. So we thought it was important to lay this out how the HIE strategic plan and the unified health data space as a health data utility enables value-based care. So I won't read through all these items, but I think it's important to also remember that the HIE, the health and grants exchange supports, I call them the five P's, five P stakeholders. And that's the patients, the payers, the providers, public health and the policy makers. All right, Mahesh I think we can go to the next slide. So this is a visual depiction of the health data utility and the unified health data space. So we'll start at the top. I want to emphasize that it's really built around data governance, security, patient education and consent. And I think it's important to note as we talk about interoperability that we also talk about security and privacy as well because we really need both to work hand in hand together. And data security and privacy is of utmost importance to our HIE. Trust in people are really at the center of that. And there are rigorous security controls and protocols and data policies around all aspects of that HIE to really protect Vermont's health data. So the way we read this chart is on the left, we have the inputs and the inputs can come in different categories, whether it's clinical, collected at the point of care or non-clinical inputs. And then we move from left to right through the overall infrastructure. This is where we see the HIE that we're familiar with. And then to the right, the unified health data space, which is essentially a data warehouse of structured data for reporting purposes. So as we move over to the right-hand side, this is where we have that data access and analytics layer made available. And we'll really start from the bottom looking at that clinical care. So that is real-time, real-time exchange of data from the HIE to support point of care. So the provider portal, care coordination tools that we'll talk more about, provider analytics. So a future item that we would like to add, provider analytics, as well as a patient engagement portal, which, again, future item we would like to add. That's consistent with last year's strategic plan. And then the three items above that are really the analytics layer for different stakeholders. So a workforce analytics layer for healthcare, public health, population health, and Vermont Medicaid. So again, all controlled through authorized access and role-based security. So, Mesh, if we go to the next slide. So we'll cover the key accomplishments over the past year. Again, we're not going to talk through each item here. As you can see, there's a lot of green on the chart, so we largely accomplish what we set out to accomplish. There was one notable item that we had to pivot our strategy on early in the year, and that's around the data warehouse. So as you can see, there's a line on the on-track column associated with procurement. So we are currently in active procurement for a new data warehouse. That vital will take over operating once it's up and running. And this pivot on strategy delay around that had some cascading effects to the other items that are in red. So they're all linked together to that pivot around that strategy. We'll talk more in depth on the governance and the policy items, so I won't cover them on this slide. But I do want to note on the funding, if you recall from last year, we talked about a major milestone that the HIE accomplished, which was receiving CMS certification. And this was a key item as it related to and relates to the funding sustainability and the amount of funding provided by the federal government versus the state share. So as such, based on that change, the funding continues to be strong and outlook is positive for our funding structure. I'll touch on technology briefly as well. And so a key item that was accomplished in 2023 is all the designated agencies are connected to the HIE. So they're currently in testing mode, but they have made those connections. And I'm looking at Christina because she works with them every week on that. So that is a major accomplishment both from the technology side, but probably more so from the data governance side as well. And then we also completed the connection to the National Health Exchange. So, Mesh, if we're going to go to the next slide, we'll touch on a number of the data governance accomplishments that we had. So we formed, like we committed to, we formed the HIE Data Governance Council. We created the structure, the charter, ongoing operations. We met our monthly cadence throughout the year. We also formed and completed 42 CFR Part 2 data governance. So this was a major milestone where we worked for about five months with the DA's to design data governance to support substance use disorder. So a really great example of partnership and collaboration across the DA's and vital and Vermont Care Partners as well as the agency. The next item, we are in process or at the relatively early stages of designing the social determinants of health data governance. And then the next two items are associated with patient education. So by state continued to provide health data education to their community health centers and they do an outstanding job with that. And vital has also continued to meet its commitment on patient education. You're probably familiar with hearing that in the news or media very recently. It's ongoing right now. And then a key item here, which was a follow up from our last session when we met was there was a request to consider having open meetings for the HIE Data Governance Council. So we had met and we discussed this and as such will be hosting open meetings, meetings open to the public starting in January 2024. And all the material we have in all our meetings, they're all posted to our website. We have the link here in the website's health data dot remote dot gov. In some hush. So the next big chunk for 2023 that we'll look at is really on the policy side. So the first two items they they go hand in hand these are associated with public health. So as we mentioned last year, they're working, we were working on a pilot, which we have implemented. It's an implementation phase of bidirectional exchange of immunization data. So immunization data from the Department of Public Health immunization registry directly into providers. And this has been a really positive, good news story. We get lots of feedback from providers how much they love having the data directly into their EHRs for easy access. The next item, as I said, they go hand in hand. As a result of the COVID pandemic, it was noted on a national level that states could benefit from a deeper integration between their public health. Departments in their HIEs. So they offered grants to states to improve their immunization connectivity and connection with their HIEs. However, for Vermont, as you're probably aware of the pandemic, Vermont has a really advanced HIE in public health relationship. So instead, Vermont applied for that money, received it, used it for the bidirectional data exchange, but also was able to use it to design a strategic roadmap for what are the next areas of public health that should be considered for integration into the HIE. So for better public health insight and better use of resources across the organization. This roadmap is on schedule to be delivered Friday, so we're very excited to see what the consultant has recommended for us. As I mentioned, the next one, the designated agencies all connected to the HIE. And then we have included in the plan in last year's legislative session associated with Act 167. And I know Green Mountain Care Ward is very familiar with Act 167. There was a request in there for a V-Cures HIE integration plan in this year's HIE strategic plan. So we have complied with that request instead of recommending a V-Cures HIE integration plan. In the strategic plan, we have recommended a somewhat different approach, but we think arriving at very similar benefit and value. And this is working directly with the payers for having the claims data provided to the HIE, to the clinical data linking up with that. And it's probably useful to note that Medicaid, this work for Medicaid is already underway, so we'll be able to use Medicaid as our pilot and see how that progresses. And then the last item here, we had met, I think it was around springtime, Beth had shared this with the Green Mountain Care Board members in one of the meetings. But we have agreed upon approach with the HIE steering committee around the national exchange. So the steering committee has agreed for Vermont providers and providers in neighboring states to request information from treatment purposes to be able to receive that through the HIE. So that helps facilitate data at the point of care. So this is consistent near the year, the overall strategic planning process. We have four main inputs. One is the federal health information technology plan. We are aligned at a national level and that's important to us. And also aligning on the national standards and best practices. The next item, which feeds into the strategic plan is current year accomplishments and status. So I think it's worth noting, hopefully, for those who have read or are reading the plan that we adopted a slightly different approach on the narrative of the plan. So we made an effort to make it more precise, easier to read, easier to digest. So hopefully that was an improved benefit for those who are reading it. The next item is the HIE steering committee planning session, which occurs in September. So really good turnout for our planning meeting. And then brilliant. We continue to partner with brilliant as a consultant on data governance. And is Kate. Oh, sorry, I have one more. And as Kate mentioned, this is a one year reflect refresh for the five year refresh. So a lot of the items are very consistent year to year, as we would expect. All right. Thanks. So here are the 2024 strategic items. We have laid out the goals on the left. And on the top across, we have different columns. So we have a foundational column. We have two columns associated with themes at the national level. So value based care, focus on health equity. And then the four columns to the right are the HIE goals that we saw on page three. So I will say the checkmarks are fairly subjective. So I wouldn't focus too much on where the checkmarks are, but more on the content associated on the left with the goal. So I'm just going to kind of talk through top to bottom on the different goals for 2024. The steering committee noted, we will likely continue to have data governance as a strategic item for many years to come. So that's just a heads up that that will continue to be there. It'll be ongoing operations plus any new data governance domains such as social determinants of health or depending on what the public health integration plan looks like, public health data governance as well for that. The next item is ongoing support of the data of the patient education that we heard earlier regarding by state and vital. So we certainly want to continue that as well as provider outreach for HIE awareness. So it has come up throughout the year that providers and the provider community could benefit from more outreach about what is the HIE, what is vital, how can it help and serve the provider community. So we want to support that. And it's probably also important to note in this one year to year we requested a little over double the funding to support patient education since it's such a critical item and that funding request has been approved. So we'll be able to provide additional patient education as well as that provider outreach. The next item includes a number of components here. So it includes data standardization, data quality, completeness, ongoing connectivity. So continuing to connect providers to the HIE as well as a new program that we're running, which is a provider incentive payment program. So this is specifically focused on home and community based providers and those providers have not yet had the opportunity to connect to the HIE under ITEP. So this is an incentive program where the providers who are eligible and there's three criteria it's on our website have an opportunity to receive funds to either move from paper system. And the research that was done this year on the Vermont landscape was about 30% of eligible providers are on paper. So an opportunity for them to move to paper to either an EHR system or an EHR light system, as well as provider incentive payments for moving for those who are already on a system to connect to the HIE to facilitate data exchange and care coordination. The next item is I'll say the early stages of an analytics layer. So it's really mapping out the requirements in the stakeholder engagement around that analytics layer prior to procurement. So that would be an analytics layer like we saw in the end user services on the earlier page that we envision vital as operator HIE would own, but got to procure for an analytics layer. And it's probably also important to note this analytics layer. Dr. Walsh mentions the shoemaking and be able to for providers to query and analyze what does the patient population and demographics and composition look like. This is what that analytics layer would provide for both the providers, payers, public health and policy makers. Again, with appropriate access and will be security. The next item is an item that HS and vital had been worked on for months. And that focuses on really examining costs for maintenance and operations of the HIE. The next item is around care coordination and referral management. So this is consistent with our five year plan that we had for 2024 to start the requirements, gatherings, stakeholder involvement and scoping for a care coordination and referral management. This is a major work effort because it's across many different stakeholders. So we have scoped it out really to be scoping requirements gathering. It does not include any procurement plan for 2024. So I just want to be upfront with level setting expectations. The next item is around a strategic roadmap for social determinants of health. Recognizing that's a key item associated with health equity. So as a state want to ensure that we have a strategic vision around social terms of health. From a data perspective as well as from the provider's perspective and payer and policy maker. In 2023, we had the plan for integrating the Department of Health into the HIE. This year, as I said, we plan on receiving that on Friday. We plan on executing the work associated with the items that are deemed on the forward. That will be in 2024. So the actual execution of that plan. The next item is new year to year. This was surfaced during our planning session. Also surfaced during that landscape review around Vermont Health IT Landscape that the consultant for the Medicaid data access and aggregation program did. And it's really about better exploring and understanding options for our rural providers in smaller practices to engage in the health system electronically. So very tough at times to scale some of their large practices where they don't have IT support or that IT expertise. So how to better devise strategies to make sure they're part of the overall health system in a way that they want to be. And lastly is ongoing technology enhancements. So focusing on standards based APIs, which will enable future functionality, as well as scoping out and requirements gathering for a provider directory that could be used across the health system. So those are the main items we have for today. Mesh, I think you can stop sharing and we can hand it back to either Kate or a chair foster. Go ahead, Kate. Thank you, Kristen. So I'm not 100% sure if we're going to listen to vital and the connectivity criteria first or if you would like to do questions. For the HIE plan specifically now. I hadn't thought of it. Does Kristen, do you have a preference or Kate, either of you. I think it'd be nice to hear the connectivity criteria to just as it kind of just sort of relates to the, the, the work and the improvements of the be high. So why don't we do that. Christina, if you do, if you're ready to go, we can have you present and then, and then I'll come back. Sure. Can you make me a presenter, Kate? I don't have the power. I can share your slides. If you don't mind driving. No, I don't mind. So let's see. You have them. You see them. There they are. Great. Great. Well, thank you everyone for allowing me to be here to present this and we'll just go right into the next slide. I think Kate. So let me just reorient you to what the connectivity criteria is. So it establishes with healthcare organizations the criteria that we need on the be high in order for us to accept data and just sit into the system and prepare it for sharing. And so the original be high baseline connectivity criteria will remain unchanged and there's a very good reason why that baseline really sets the stage for informing the healthcare organizations that the data needs to be structured in such a way that we can accept that data and use that at the point of care. It also establishes the criteria that we need to be able to either create a new patient record in the be high or make sure that we are matching the information to an already existing record so that we have one record for every Vermonter that contains the student health data. The new piece of this is the connectivity criteria tears and I'll get into this a little bit further but the tears have been revised to align with the United States core data for interoperability or us CDI. Although we have included the data elements in the past in the connectivity criteria and we've aligned where changing the narrative to really take the be high kind of connectivity criteria and make it really aligned with the US CDI and not have it be so Vermont specific and you'll see why in a moment when I explained the benefits of doing that. The US CDI. They are criteria that are published by the ONC the Office of the National Coordinator for Health Information Technology and we want to leverage that type of standard and it replaces the 2015 moment clinical data set which when we created the be high connectivity criteria years ago, it was aligned with that 2015 so we've grown the connectivity criteria through its many iterations to align with the ONC changes. And as you'll see in a moment, similar to the original be high connectivity criteria, there are common data classes data elements and terminologies and all of this is to support interoperability. Next slide please. So what exactly is the US CDI for those who don't live in this exciting world that we do at the be high and at vital. It is a standardized set of health data classes and data elements as I was explaining, but it really is to support nationwide interoperable health transformation exchange. So not only does it meet the needs of Vermont it really meets the needs of any of our data contributors, and we support that national exchange. It's broken into data classes, which is a theme of data for example vital signs, then the specific data elements that fit within that class so with worth sticking with vital signs systolic blood pressure diastolic blood pressure, you know all of those types of vital signs, and then the terminology the standardized terms that that healthcare organizations and their vendors should be using. And in several cases there may be a couple that you can choose from, but they should be standardized industry codes like loyne snow med CT and rx norm machines like codes, and that's why those are used in US CDI is updated annually, similar to the be high connectivity criteria so again starting to align, or continuing to align with the evolution of the national standards, and those US CDI are meeting the evolving needs of health information exchange throughout all of the use cases. Next slide please. So, if you can't see why we would want to do this what the benefit is the alignment with US CDI really advances interoperability, which is the whole purpose of the be high connectivity criteria to continue to advance and mature in interoperability. So, as I've explained the US CDI establishes that common data set for health information exchange, and it primarily the US CDI was established really to allow for patient access and so we want to support that. The ONC has required that EHR vendors or health information technology going through a certification program with them, they are required to exchange or they must be able to exchange these US CDI data elements to be certified. The required versions are regulated, but the vendors are encouraged to update to the latest version at any time, and this is important because right now the current standard is US CDI version one. But again, EHR vendors are encouraged to move on to the next version, version two and version three. And through that they are the ONC is actually having a proposal that beginning in 2025 US CDI version three which obviously has more data elements will be the required version and we're looking forward to hearing more about the final rule. US CDI is required for any type of document based exchange and for APIs. And so we've talked in the past about fire, the fast healthcare interoperability resources. And so this is the US CDI is nicely aligned with the data elements that are needed for fire exchange for interoperability. And if you're following what's happening, federal programs, clinical practice guidelines are also aligning and leveraging the US CDI to say, let's not come up with something different. Let's make sure that we too are using the US CDI defined data. And for the hope that one day everybody will just be using US CDI, and it's become part of the narrative and part of the norm. Next slide please. So this slide may look familiar to you because we have used this every year in order to demonstrate the connectivity criteria and the maturity model. What's different this year is that we've changed the tier numbering. So we have a new tier zero, which is our baseline connectivity, which is not changing. We need to stick with how can you make a secure connection. How can we make sure that we're matching patients. But the tiers now are aligning to the actual US CDI versions that have been published. And this allows for healthcare organizations and their vendors again to move along that maturity model and grow into the latest version that is available for them to be able to meet and send standardized data to the be high. And it's good for the healthcare organizations and their vendors to know how they're moving along that journey. Next slide please. So this slide is for anyone who'd like to know more about US CDI. It's a public website that anyone can go and look at and learn more about US CDI. And then the next slide. I think sometimes visuals are helpful. And so this will show you for US CDI version one, which is the current standard for certification for health information technology for the EHR vendors. Here are the data classes and the data elements that are in here. Knowing what the right terminology is requires access to that website, which goes into more detail about the terms that are used. And that's the high connectivity criteria. Thank you. Thank you. So I think I'm going to get it started with just a couple of questions. So these are staff questions. And then, then I'll turn it back over to you chair Foster for board questions and so on. So I think these are related to the HIE plan, but I think it's AHS can respond, but I think vital may also want to have an opportunity to respond as well. And that's perfectly fine. So in the HIE plan, you talked about and of course addressed the vitals continued commitment to patient and provider education as an accomplishment for 2023. I just wonder if you could describe if there are any strategic plans or improvements related to this for 2024, particularly around the focus on health equity and the plans for improving provider awareness of the HIE. Yes, do you want me to start and then we can tag team? Yes, okay. And these are rough numbers, but historically, we have about 200,000 for patient education that aside each year. This year we're out looking for 100,000. We are really excited about that. So it's again almost double what we've had. So yes, we want to add the provider outreach to that. Again, we heard from members of the steering committee that that that's a needed and desired item by providers. And we also heard from the landscape assessment from PCG public building group who worked on the home and can be based providers, the set of providers that have not yet had the opportunity to connect to the HIE. And the numbers they had there were only 2% are using vital access currently, but more than half on two. So there is a strong desire and a desire to learn more about it, which I think we really should tap into to improve the overall health care landscape. And for the patient education, I will say we don't have a, we don't have very operational detail determined yet around the additional money on how we want to allocate that. And I'm very curious, as we have our steering committee meetings in January to hear from healthcare advocate and other team members on how we want to best approach that to make sure it's good use of state funds as well as comprehensive across the structures. That's do you want to comment. Yeah, you know, I think I just like to say like we do take that part of the work that we do as a very important part of the work of the high right both to encourage providers to participate, but also to make sure that they understand what we do and really to make them understand how the opportunity to understand how their data is shared and potentially used. As Kristen mentioned earlier, I don't think you could avoid the public outreach that we've been doing now Marines team and her team have done a great job of really taking on some new media channels you know we with the pandemic were cautious about how we communicated frequently because we didn't want to outshine the important public health messages that were were coming out particularly from the Department of Health and we really kind of this year you've seen we did a campaign in the spring and we're doing a big campaign now with some really new media channels to really start that outreach. And you know it's what's interesting, you all may know this is that most states this requirement is not considered with the he right they're allowed to do what they do and there's no kind of importance placed on the public outreach and educating patients really in particular how their other data is used and we do get recognized for this when we work with our peers and it's something that we take very seriously on low absolutely continue to do. That's great it's great to hear all of that. I, I think, Kristen I think I saw in the slides that there was a slide about with metrics and KPIs I don't recall that you talked through that but there was there was a metric related to the number of patient queries through the V high. I didn't I didn't see the metric I know you're talking a little bit about this but around provider use metrics and what made me think of it is the well a couple of things in the in the HIE plan there's a reference to health e link which is the health information exchange in western New York. And in one of the citations that one of the citations is to a mill bank foundation. Research study where in that within that they acknowledge that I believe they're referencing other research in this acknowledgement but they they say enticing providers to actively use the services provided by the HIE to the fullest potential remains a challenge. And so I just wondered if you you're speaking to that a little bit but it also made me think about the provider incentive payment program, as well as the I sort of wondered about the plan for provider analytics and does that apply to like is that part of the encouragement and the enticement to you know, you know, use the providers using the V high to their fullest potential. That's all common and maybe we can tag team down. Yes, we have a slide that we've included. We also keep our website up to date so you can see how update the metrics. They are required metrics for us to provide CMS quarterly at a monthly granularity. That's part of the outcomes based certification. And so again that's on the website. It's really interesting on the, the metrics Kate that you're talking about is Beth and I have been talking about engagement metrics, what are the, like, I'll say right engagement metrics. And that's really important. I believe you get what you measure and what, what exactly do what outcome do we want. And, you know, we've talked about is number of vital access or user by access, but we also talk about directionally, you know, from providers, they want to receive more of their data in their EHRs, having one more website to go into. It doesn't sound like a big deal, but one more website to log into really is a barrier. So we would like to have more data directly loaded into providers EHRs. However, that wouldn't come up in a provider portal metric. So, Beth and I have been talking about this. So probably be, I suspect that a few more months of discussion until we settle on engagement metric that feels appropriate that we want to move forward with what are your thoughts on that. We think that's right, right? Because I think in Kate, you know this you're going to get our quarterly report today sometime if you haven't received it already this morning, right? We do provide some information on usage of the portal and we do break it down by provider type, right? Which I think is an important view to Kristen's point. Some of them, the barrier is having another system. For some of them, they don't have systems to access data. So it is very important piece of their work, right? And I agree, Kristen, like it's getting the metrics right to make sure that we're measuring where it's not just which providers are using it. Are we getting it to the right providers who really need the benefit of the data and we want to drill down into that. You know, I think we've seen a lot of uptake and usage of the portal, but absolutely the demand is to get the data into the HR. This work with the health exchange that Kristen mentioned earlier is one step forward to allow access. One of our biggest stakeholders, you know, is working to get the data in their EHR in that way. And we want to kind of continue to make the portal available because not everybody's going to have another way to get that data. You can ask public health, good examples, but also find these other avenues to make it available for them as well. And so we'll want to make sure the metrics measure all of the access and not just one piece of it that might not be as meaningful of a story. Great. Thank you very much. I appreciate your response to those questions. I think that really helps kind of fill out some. Some of the information that you presented today. I think I'll stop here and hand it over to you. Chair Foster for board member questions at this time. Thank you. I'll just open it up to the board members. I can go first. So thanks so much for the presentation night. I appreciate the briefer version of the HIE plan, but it's still a solid breed. So whatever it was, 63 pages is nice to come down from whatever it was previously 120. I have several questions, but maybe we since we're just talking about a topic that I have a few questions about, which is the data integration to EHR is it sounds like you're explaining there's this complicated issue of how do you measure the uptake of that data usage because you then lose, I guess, access to understanding if it's being used. But other than vaccines, is there that sort of that bi-directional data that you talked about going into EHRs at this point and how is that process going? Beth, do you want to talk about results to look for? Yeah, yeah, I think we have this in a couple of places. Delivery is a good example of where we do that. We get on behalf of a number of hospitals across the state, mostly lab results, right? You go in for blood tests, that type of result. We deliver those, that data on behalf of those hospitals to community providers directly into their EHRs or their workflows. That's something that we've been doing for a number of years that we will continue doing and that's a great example. Most of those providers don't even know the data is coming from vital. It shows up and we are just behind the scenes delivering. And I think that's an important piece of the work because it saves the vaccine and the phone calling and it just is at their fingertips. This work with the health exchange is another good example of getting the data into the EHR. So you may be familiar, like Epic is a good example of there's a component in there where you can search for national on national exchanges for data on patients. So you still have to go click a different button in the EHR to pull up this data, but it's an opportunity to then access it and see if it's data you want, where it's from and data that you want to use. And we're hoping that we can work with more providers to make that available. There's a little bit of a challenge in where we can make the data available into EHRs because not everybody wants the data just to show up in their EHR because they can't vet the data, right? They want to know, is it a reliable source? Is this data I want to include in the patient record? What legal ramifications come from that too? So it's things that we need to kind of work through with each of the provider organizations as we work with them on how they might want to access the data. So I think there are a couple of different components. Another thing we're exploring right now and don't know that we'll go down this path is there's an opportunity with this fire platform that we have to do apps with any EHRs that might pop up. So you don't have to log into a different system, but it still pops up as a different screen. So that may be another way we explore to get the data at the fingertips. So I'm sorry, just touching on your initial point is like it's definitely expanding beyond just the, I don't mean just, but the immunization data to be more complete patient record data. A pretty common theme in many of our Oliver Wyman listening sessions and the primary care advisory group is the challenge of getting data from other hospitals, clinical data. I think, especially smaller hospitals, I think feel frustrated to some degree providers, these smaller hospitals because they're not part of these larger EHR networks like Epic and Care Everywhere that goes with that. Are you able to, I guess, in working out these interoperability with data and getting data presented to providers within EHR? Are you, is that working with all hospitals simultaneously or picking some that are, how's that going? Is there a way to get it to the smaller hospitals that seem to be crying out louder than the larger hospitals? No, that's a great question. You know, I think some of where we want to go is with this eHealth Exchange connection because it's not uncommon for EHR to support the ability to get data through that or access data. So we'll want to work with them because women has a component built in that's more straightforward. So we're working there as a start to make sure we do the testing, make sure it works so we can start to work with some others. And then we are having conversations to explore what else might be possible. I think you're right. It is definitely a lot of the smaller hospitals that we want to work with to see how we can supplement some of their data needs. Okay. I want to pivot to a different question that came up in your presentation. So can you just explain to me the significance of the, of the connecting to the National Health Exchange or what that means to your honors? Yeah, I'm okay. Yeah, I just didn't want to do a presentation. Yeah, so I think the there's a couple of couple of things I'll say to answer that. I think the significance for that is, you know, we have a lot of patients or a lot of the population who travel who might have a second home, right? So the availability of their data at the point of care in other places I think is really important as well as people traveling to Vermont and they end up in an emergency room or something. So having access to that patient data I think is a really important piece of what we provide to enable them to have better care. It's also steps towards goals that are really being driven by the Office of the National Coordinator for Health IT and CMS, Centers for Medicare and Medicaid Services to really encourage this national exchange so providers have patient complete patient records everywhere and it really is accessible You know, they're really pushing towards this goal of the what's called TAFCA, the Trusted Exchange Framework and Common Agreement, which is really has a goal of having kind of one day, like, not next year, but one day, CMS exchange between providers so the data is available for the traditional HIPAA purposes, right? The Treatment, Payment and Operations goal. And so I think our taking these steps helps us provide more data. Our participating in these national exchanges makes more patient data available to our providers because we can query these exchanges to get the data for our providers and then help us take steps towards those national goals for interoperability as well. And so my impression is that, that as of now, we're you, we as the big Vermont, we are working on developing the connections, but are we getting data flows? I mean, as a clinical provider, I don't know if I'm getting out of state data on patients who I'm seeing in the emergency department. So those are the connections that we are working on right now for eHealth Exchange and so you would start to see it. Our initials foray into that is not full national exchange and you may recall, and Kristen mentioned earlier in May, we came forward with a change to the appendix A to the plan about access to data because of the changes in reproductive care data and gender affirming care data is used and potentially in other states for non-treatment purposes. We have decided to take a slower entry into that national exchange. Well, we kind of explore other ways that we can protect that data for patients that want that data protected not to be used in other states. So our initial kind of foray into the national exchange is specifically with local providers who want to exchange V-high data as well as the Department of Veterans Affairs and the Department of Defense for their healthcare, the joint HIE, they call that, which serves their medical facilities and so be access to that data. And we're hoping that we can address some of the concerns about reproductive data so we could open up really more widely for providers to be able to have the national access. Okay, great. I want to talk a little bit about some stuff in the submission. I mean, within Act 167, the language looks to say that there's, you know, to develop this plan to integrate claims data with clinical data and there's a significant amount of the submission that's basically related to this. And so I guess there's a lot of questions about what's written there. The first is on page 14. And I think Kate O'Neill was discussing this study with New York Health E-Link, which I think she's probably far more familiar with the study that I am, but some things that kind of were quite striking is this 24% reduction in re-admission rate, 21% reduction in outpatient surgeries, almost a 33% reduction in hospital length of stay and a 30% reduction in re-admission rates within 30 days. And so those are really striking outcomes. And so I guess one, you know, the first question is, you know, can you walk me through this evidence? How does this relate to the integration of claims data and the clinical data to lead to these striking outcomes? Well, I will say I have the same level of information that you have with the footnotes. So, yeah, it is really striking. It's a pilot program that the HIE in Western New York has done with claims data, integrating claims data, and also leading in the population health. I think it's a great example of what can be done when we think about bringing those data sets together for providers. And I guess a few, just a few questions in this, do you know, like when this data is from or if there's a comparison group or if this is COVID related or? I'd have to look at the footnote. I recall it being fairly recent in the last two years. So I can go look at the footnote and be supposed for it. Yeah, I, you know, these are the kind of data that, you know, that really, I mean, they're quite striking numbers. And I guess I just, I get, you know, I get worried a little bit when we see 24% reduction in admission rate. Are those good admissions? Is this emissions we want to reduce? Is there something else going on? Is this inappropriate reduction? Is this, you know, is it inappropriate or appropriate? Again, at outpatient surgeries in a short period of time. Is this because people are getting better care or is this because there's having or having access troubles? I just get worried when I see data like this, as well as equity reasons, you know, are we seeing, is this an inequitable or an equitable distribution in the change in patterns? So I can certainly put you in touch with our contact at Deloitte who worked with the contact associated here to get you more information on that. I certainly don't have that information or that depth of detail. But I suspect Deloitte would be more than willing to meet with you and discuss it. I think that would be helpful. They are striking numbers. And again, I guess just moving a little further down in the medication reconciliation. I mean, this is an area as a provider. I actually wrote out like a paragraph, but it started right. All the times when having appropriate great medication reconciliation is so important. It is like, it's, but it's the challenge. In fact, another Oliver Wyman listening session or two providers complaining about challenges of medication reconciliation with people getting healthcare at, you know, within different EHR systems and how complicated this is for providers. And I was trying to understand and think about the integration of claims data within clinical data if that's going to solve this problem. But definitely the first concern that I had is the claims lag. So understanding the claims lag, what do you think about how that's going to affect this? Or what's the plans to address that? Yeah, I think the claims lag, I will say is we walked through some of the working meetings with beacons. The claims lag was the number one concern that I had as we worked through items. However, I think the pilot program we're doing with Medicaid will be really telling. We've also had some really interesting and productive discussions with CMS Medicare who are making their claims data available at the point of care for providers and healthcare organizations. And they noted that for their adjudicated claims, their time lag was seven to eight weeks, which is pretty good. I think that may be almost as good as it gets for adjudicated clients. Yeah, I would just sort of state a word of concern about that from a clinical standpoint because of the clinicians relying on the med list being updated because there's some consolidated database and seven or eight weeks can be a long time, especially if someone started a new bed three days ago from the standpoint of the world of emergency medicine. Sometimes people come in quite sick, altered, obtunded after starting a new medication that is having a bad reaction with something else. It's not often they come in. This is a rare situation. I don't want to be overly dramatic on that. It's an occasional situation. That's when really that medication reconciliation is like the most of the most high priority. And so I think the claims lag, at least from my perspective, does definitely create a challenge with the usability of the data. But then further down in that section on page 16, you discussed two studies that show pretty dramatic expenses associated with non adherence to medications, $100 to $209 billion a year in the 2000s and then another one that was $528 billion in 2016. And it seems that the way this reads is that it's implying that if we could get claims data into clinical data that we could save proportionally this amount of money due to medication adherence. And I don't think that that's what these numbers are representing. Am I sort of misinterpreting what the I can go back. I believe this was a direct quote from the study. Yeah, so it says last two paragraphs. Yeah, a more recent study estimates that the annual cost of prescription drug related morbidity and mortality because of not optimized optimized medication therapy, including non adherence medication non adherence was 528 billion. I wouldn't want someone who's reading this to leave thinking. Oh wow like if we could just fix medication non adherence through integrating claims data and clinical data. We could save for my portion of $528 billion a year more to morbidity and mortality. It just seems that I was just a little bit taken aback by the breadth of the assertion within the context of the the topic. Well, we welcome any feedback if you have suggestions for wording or caveats that you would like to include so Yeah, I mean I would actually take it out. Because I don't think that we could. I think it's too far removed from from the idea of integrating claims data and clinical data that you could get to saving these billions of dollars through fixing not adherence. It just seems like a very like a too far removed from the challenge from the topic that we're talking about. It just stuck out to me. Thank you very much. There was only a few others. Oh, can you also you mentioned in your presentation the US CDI. Christina that you show the diagram with the one are two in three. Are they different elements are they expanded elements are they different ways of reporting the same elements. Yes, great question so the US CDI. For the most part, they add new data elements to continue to expand the list of data. Occasionally what they might do is keep a data element but move it to a different data class, for example, but the goal is to expand the data elements over time so you're getting more and more data. Great. Yeah, I'm just looking through my notes. The only other stuff that I wanted to bring up a little bit more we're sort of just some concerns with the usability of having the claims data mixed with the clinical data. The claims lag. But also, patients who don't purchase prescriptions with insurance a lot of patients go to Walmart and buy the $4 Walmart drugs because they're less than than buying it with the insurance copay out of state care but it sounds like that maybe addressed by these national exchanges. I had one other that's not on this list I'm sorry. Yeah, I'm sorry that's that's that's the one other thing I have on here I'll have to send you via email. Overall it's so exciting to think about having a unified health record for a patient that they could that we could have real time, you know, updates and be able to get accurate data and and and have a way of communicating between EHRs and having these neutral platforms. So I'm so I've always excited about the project. I have some concerns about the, you know, the, the aspirations that we will have when we throw in claims data but but whether or not it actually, you know, but I do think it's overall such an incredibly important part of our healthcare system and delivering care. So that's all for now. Thank you. Next. So thank you so much. There's a lot of great progress and lots of things to get excited about. Maybe I'll just start. I just had a question or two about the integrations and since they've just left off with that maybe I'll start there. I'm curious if you could share what the response has been of the commercial payers, you know, Blue Cross Blue Shield MVP, SIGNA probably the top three to the notion of directly submitting claims to the HIE what has been their response and their concerns, if any. I'll ask is Blue Cross Blue Shield on? Usually Rebecca or Sarah Jean. Yes, sorry. It took me a while to get the button. Sarah, are you, I know Jimmy has a perspective that he has shared but has he shared that with you? Is that something you're comfortable sharing? Happy to show. I would jump in and say that we do have some concerns. We'd rather not be submitting the same data multiple times to multiple sources. So just the added, you know, administrative burden on submitting data. We are always concerned about our consumers privacy and the protection of privacy. And then we do have concerns about the lag in our insurance claims data, you know, that it's long enough that we're not convinced that it is sometimes as useful as some people anticipated to be. And so whether or not it's worth the cost and effort and, you know, everything that everyone puts into to combine these databases. So we do have some concerns. Is that Kristen, I'm assuming there's been outreach to the other pairs. Is that similar response? Would you say to what the other pairs would know the average is mainly been with Blue Cross Blue Shield. We use them as our main contact for commercial pairs. Again, the way we have talked about it is Medicaid is its leading edge. They'll be the pilot will gather information. We would like to continue the conversations with Medicare. They're doing some really exciting things that I think we could all learn from. And then the next step would be bringing commercial pairs into the fold. So I think Jimmy and I understand that's probably years down the road. Oh, okay. And I guess related to that. I'm just curious about patient consent and how that I know, you know, the talks about how that's very important and patients to be at the center and their health of their health data and should be able to make decisions about how their health data is used. So I'm just wondering in the new vision for integration. How does the patient consent work? Yeah, patient consent is such a core important piece, especially as we talk about like that had mentioned sensitive data around the health gender care. Part two data. So we anticipate having one of the SAMHSA proposed rules finalized at some point, hopefully in the near future, that will likely guide us to granular consent around. So I think directionally that is where we as the HRE are headed as well as probably on a national level granular consent. Got. And so, for example, like the Medicaid patients right now, are they did they consent already to having their. Through their process. Okay. Got it. Switching gears a little bit. Those are my questions largely about the integration vision. I'm just curious a little bit that the HRE plan. There was a conversation about a focus on the cost competitive structure for maintenance and operations of the HRE and evaluating that. And I'm just wondering if you could talk a little bit about how cost competitiveness is defined measured benchmark like what are what are you thinking along those lines. Yeah, I'll start. And again, maybe you can jump in. So as we think about our main operations cost for the HRE. We want to be really thoughtful about the growth rate of that cost over the future and want to dampen that and reduce that as much as we can to continue to offer a really. Affordable and structured rate for the HRE cost. I think some important items that Beth and I have been talking about over the last few months are really the actions around what would what would that look like. And we have agreement and discussion on really free key items. One is surveying the landscape of the existing technology vendors and the existing costs and price from those vendors to make sure it's as competitive as possible for the services they're providing. And the other is the focus on the indirect rate. So looking to really bring down the indirect rate for the maintenance operations and really focus more on the direct rate that we have as well as shifting from maybe some of the consulting spend to bring some of those technical skills in house in vitals. Company so not spending the premium for consultants but really bringing those technical skills in house. So to directly answer your question we don't have it in exact number we're targeting we know there are a lot of moving parts we foresee coming up and it's really that rate of growth that we're focused on. And how are you how do you benchmark it there's a look like there was some benchmarking that was being done so is it a comparison to other states is it you know what is the benchmark or comparison. That all speak and I'd like your thoughts as well. I didn't find the benchmarking that I'll say useful for what we were looking for. So I wish I could have pulled out a page and say oh yes this is this is benchmarking is what we want to do. The result. I didn't think was was as effective for for us in that manner. So there isn't a number or target or percentage that we have in mind to fit but it is working with that than vital to address those three key actions. But maybe one just recommendation might be putting a little more clarity around what is meant by cost competitiveness and the criteria and you know just because I do think it's a little bit vague in there and I think it's so important. So I appreciate the work that you're doing on that. I think my last question was around. There was a under the health data education and I appreciate sounds like you've doubled the budget on that and it's a it's a focus area which is so important. And there was a sentence in there I think through a health equity lens that is particularly this is on page 14 I think particularly crucial that reminders possess the skills to access comprehend analyze and utilize their data to make informed choices. And I know there was a mention of a patient engagement portal. And just I'm wondering if you can, you know, expand a little bit on this mean that seems huge if we can actually, you know, meet this goal of allowing Vermonters to possess the skills to access comprehend analyze and utilize their data. So I'm just wondering if you can speak a little bit to what is that patient engagement portal going to actually look like and how is it going to accomplish, you know those four goals for patients. And also wonder the same thing what will it look like. That's certainly further out. And that we had last year the five year fan more of the 2026 and realistically, and I'm just going to give you some shocking numbers here. We don't have a whole lot of demand right now from the patient side accessing data. However, I think over time that will grow. And we want to be supportive of Vermonters to develop the skills to want to interact with their data in a way that's meaningful to them. So I'll give you the latest snapshot, because from a Medicaid perspective. It's a fairly interoperability role. For compliance we have to make a patient access API available for patient Medicaid patients who want to access their data. And on average, the last two months, it's two people on average accessing their data so it's very, very low. And we anticipate that will increase people are comfortable with the Internet of things and using work devices. So we anticipate that will grow and we want to build the skill base up over time. And so patients have a right to see what's in the data in the HIV now about them and they also have a right to know who else is accessing their data. Yeah, I'll say so at any point in time, a patient can, as you said, ask for a copy of their record so they get a full picture of what we have and from where, but they can ask at any time who has access to it and we will give them an entire audit of who has looked at that record where they where they work so that is absolutely always available. Okay. I think, I think those are my main questions I will ask the torch thank you so much. Good afternoon, Kristen and Beth. It's Tom, and thanks Kate for all the other material presented. And thanks Kristen for the call out about my analogy last year with boots. I plan to say a little bit about that again, just in the beginning before I have a request. There's there's so many, so many acronyms right the hie the vital v cures, the US CDI. And you get a sense of how hard it is for all these entities to work together. Right and when we start thinking about interoperability and integration. And the point that I tried to make last year with the LL being example is that we have Vermonters who need boots. And sometimes we get caught up in making a whole catalog of all the things that we could possibly do for people there's patient provider education there's analytics engagement literacy, all kinds of things. But but we haven't made a useful boot. And so I have a an ask right something that I that I. A boot that's really needed we need it for regulation we need it for patient care. We need it for health care reform the ACO needs 1 care need it for for their efforts. And that's to recognize that we have a huge problem in the state with suicide death by suicide and substance use disorder. And some portion of that is linked with depression. And there's a lot of talk about trying to do more screening for depression. And long time ago in my clinical career, we started an effort to screen for depression in the clinical practice. And we were expecting about 2 to 3% of the population we saw to test positive. Right. And it was closer to 15%. Like way, way more than we ever thought. And so then we then we worried about getting patients to the behavioral, the cognitive behavioral therapist that we had on staff embedded in the same hallway. And we started looking at, well, how often do we use that therapist and less than 10% of the people who screen positive. We're receiving a referral to behavioral therapy ours or anywhere else. And that really caused us, you know, a lot of reflection and realizing how poorly we were doing. But we were writing articles about how great our design was embedding cognitive behavioral and practice. But we were really lousy at it. And it took a long time and a big effort to improve the utilization. And so my, my ask about data integration. It would be great if we could find a way to work together to provide at the provider level and then be able to aggregate up to clinics and practices. But at the provider level that the number, the proportion of patients who are screened for depression. And then the proportion that actually are positive. And of the patients who test positive, how many receive a referral. Because that's not as clear as you'd think people, clinicians who aren't cognitive behavioral therapists aren't always comfortable making the referral. And the patients who receive a referral. How many are seen within a day. Within two days. Within three days. Within a week. And within two weeks. Beyond two weeks is a huge failure. Given the suicide rate that we have in the The trouble that depression causes. So my guess is that a lot of patient, a high proportion of those patients. Would be over two weeks and it helped us understand the work we need to do. But of the patient then of the patients who are screened and test positive. What proportion end up with an ED visit. For mental health. And what proportion die by suicide. None of those numbers are hard to get any one place it's hard to package them all together. And none of that type of analysis requires any fancy math it's fourth grade division. But I haven't been to a clinic yet and I've been to hundreds just in the type of work that I've done with the joint commission and other places. Nobody can do what I just outlined yet. And I think the people who have the same experience as me that they can't. And it seems like we have an opportunity with our small state. To be able to do something like that. And with the trends in healthcare that ahead model the next all payer model. There's there's a lot of a lot of emphasis on equity. Well, if we had those proportions of percent screen percent positive. We have a lot of people who die by ED percent who die by suicide. And we stratify that. Plus or minus substance use disorder. By gender. By race, ethnicity and by payer. Then we have actionable equity information. And this is way beyond. Which is what we are talking about in our state right now. Which is the simplest. Measure possible. And very weak. It's enough to say that we've started. But it's regretfully poor. When it comes to managing these patients. So. Outlining being able to do an analysis like I described. It creates. Operate lots of opportunity for action. So we need this type of information as regulators. But care providers need it. ACO needs it. The state has a has a it's either a monthly or a weekly. Report at the department of public health. On suicide. So we need this type of information to be shared. And there's very little actionable data there. This type of information could be shared there. That makes it actionable. So. I thank you for coming in and I thank you for sharing. What you're working on. But I want to go back to the example we. Rather than continually thinking big. I think it would be helpful to think in a really targeted way. I think it would be helpful to think in a really targeted way. I think it would be helpful to think in a really targeted way. Right now. Mental health. And the number of people were losing due to suicide. And there's a chance. For HIE. Vital vcures to work together. To help us with that. So I'm asking for your help. Thank you so much for sharing. And I think that was. Really. Great to hear your perspective. I'm looking at the hash. I trust that we have. After that. But that was outstanding. Thank you so much for sharing that. And I, I would like if. Potentially if you're available. When we do start our requirements. Gathering session for the analytics. I would love to include you. As well. If you're available. Do my best. I'm happy to help. Thank you. Thank you so much for joining us this afternoon. And go ahead and jump in. Are you. You're done Tom. I just don't want to. Jump in if you're not. Thanks Robin. I'm done. Thanks. Thanks all for joining us this afternoon. So I have just a couple of clarifying questions to start with. So it sounds like for both the analytics layer and the care coordination. Platform 2024 is really the year of. The end of the year. The end of the year. Is that what you've done in 2025. For the care management. Yes. No. Next year. Beth and I were talking about the analytics there. I would love if we could move a little faster on the analytics there. And I'm just going to be totally transparent. We have a grant for it. It's available through March 2025. So. If we can take advantage of. Okay. Yeah. That's helpful. I think with some one of the things that would be helpful for me. To understand with the strategic initiatives in 2024. Is. Is sort of this kind of a timeline with which part. What's the longer process. Which part will be done when just so that it's a little easier to understand. Like. What would I want an update on before next year's strategic plan. For example. Versus. Simply waiting. I don't want to ask for updates that aren't necessary before next year. But certainly it sounds like there's some things that might come be further along or come to completion in 2024. And given the level of detail in the plan. It would be helpful to. Understand. A more granular idea of what's going on once we get there. Yeah. That's great feedback. And. Looking. He has these great can charts that I know he can create for that. So thanks for mentioning that. Also Robin. I love a chance chart. So do we. For the engagement model that we have with. Both three mount care board. But every steering committee member. We do provide updates. Operational updates throughout the year. Four times a year. That information will. Be included. But certainly if you want more information beyond that. We are happy to. That too. Thank you. On slide. I'm going to just switch my screen so I can actually look at the slide on slide. 11. Which is the unified health data space graphic. I think I understand from the text that this is the vision. One thing that would be helpful for me. If it's possible is to somehow color coordinate. Or color code. The different pieces that are future looking versus in. Place now. So for example under clinical care and the data access and analytics. But we have a provider portal. So that's something in place now. Patient engagement portal is sometime TBD. Just so that it's a little more clear what's in place now versus where we are in terms of developing that vision. I guess. Absolutely. That isn't terribly challenging. I would love that little tweak. Yes. Absolutely. Thank you. So sort of similar to building on what Tom was talking about. On slide. Five. You have the. The graphic that shows the HIE. With the foundational services exchange and end user services. I guess my question is. Are we happy with where things are on each of those levels? Or are there areas that we still feel like need improvements in order to. Have usable. End user services. So you gave a good example of the provider. The provider. I'm forgetting the name. The provider directory. Thank you. Thank you very much. Thank you. I'm forgetting the name. The provider directory. Thank you. As something that you're hoping to improve this next year and reduce redundancies. Are there other parts of. Of the either the foundational services or the exchange level in particular that you think are works in progress or you think we're pretty much solid in where we are in terms of implementation. Yeah. I would love your thoughts on this. And Beth, don't feel it put on the spot. If that's something you need to think about, I'm happy to have, you know, you send something or, you know, whatever is the best way. I appreciate that. And I'm probably, well, I think I'll give you a quick answer now and then follow up with a more thoughtful answer. If you're, if I have that. I mean, you know, I think what I would say is like, I think we've. Done a lot of good work against that, but it's also like technology changes and needs change. And so we have a good foundation. We met the goals, but I think the. To use the sports analogy, which I don't normally do the goal line moves, right? And I think there's more we can do. There's always going to be more we can do. So I'm never going to say we're there. We're done. Like there's always going to be progress we can make. But I do think like from a foundation, we have a strong foundation and have to have met kind of the goals of what the initial intent was. Thanks, I guess the reason I'm asking this question in part is because in my mind it's connected to the M and O costs, because obviously the end user services for those that aren't in place yet, there's a development cost, but then there will be a maintenance and operation cost. And so if you're adding new services or you're redeveloping foundational or exchange layers, like that's. And you can tell me if I have this off base, but that will impact your M and O costs over time. And so I think having an understanding of how those two connect would be really helpful. Great. Okay. And you're spot on and not understanding. I guess my, I want to be mindful of the time because I'm sure Owen has a couple of questions and I know we have another agenda item. The, I guess my last question is I wanted to understand. The procurement piece a little bit better. It sounds like the state is doing the procurement. For the new data warehouse and that would be a vendor who provides a product or is that a software product? Like what are we procuring? Am I right that it's the state? And then I think you said that vital will then take over. And so I just want to understand like, why are we doing it in this sequence? So I have the sequence, right? You have the sequence, right? It would be software as a service. And yes, it would be the state's procuring it. Doing the DDI and then handing it over to vital for the meetings to operations. I'm looking at that. I think the, yeah. To clarify, this is the Medicaid. Yes, yes. Yeah. To directly answer Robin's question on kind of why. We, and I'm looking at you guys. So feel free to ring the end. When we started originally with the data warehouse, we encountered some challenges on contractual terms around the financial side of things. So this navigates us through those challenges, does not present those challenges. Beth, would you say it differently? No, I think that's absolutely fair. I think there were terms required for that contract that were different from the typical contract we had and put some risk, would have put some risk on vital that were beyond what we typically take on. Okay. Got it. And I assume those terms are probably connected to the MMIS or whatever we're calling it now. Yep. Exactly. Yeah. Okay. Great. All right. Thank you everyone. That's it for me. Just a couple of really quick ones. For the commercial payers to directly send the data, would there be any cost or additional costs that they would have to bear to do that? It's too early to answer that question. We would need to see kind of where we are in terms of standardization with the data. We certainly wouldn't ask for request commercial payers to reformat their data in any way. However, again, we'll have to see where we are in terms of API and API development on the payer side in the next few years. It may be something they have in place or it may not be. And if it's not, then that probably will be an additional cost. But again, I think it is we're probably too far out to really answer that question with a whole lot of accuracy. Fair enough. That makes sense. And then the mechanics, I was looking at the use cases and to do the reconciliation, what are the mechanics? So like in an EMR to do a med reconciliation, it does it on its own to do a drug, drug check or whatever. I'll have a pop up and show you to do it with information from the HIE. How does that work mechanically? So you have the patient, you have the record. How do you then connect with the HIE to do it? Do you know how to best answer that? I may ask a clarifying question before I answer if that's okay. Yeah, please. Just to be sure I address your question properly. So are you asking with, so if our provider is in an EHR and how they would use the HIE? Yeah. It was page. There are some use cases. I think it's page 16. Maybe use case one. Yeah. Right. So I'm wondering how a doctor actually in practice mechanically uses the HIE to perform that function. Got it. Kristen, I'm going to answer, but you're intended to be different in the plan. So stop me. So typically what we have in the HIE is prescribed medications, right? So we will know from all of the providers that this patient has gone to, this is what has been prescribed. We currently don't know what has been filled, which I think is the gap that often exists. And any of the providers on the call, on the board that want to correct me too, please do. So what the hope is, is that by having claims data, we could actually have information on what medications were prescribed and then filled to give a better sense of what the patient might have actually been taking as opposed to just prescribed. And so that would be the goal is to be able to have both of those pieces of data in the EHR to give a better picture of what the patient is potentially taking. Of course, nobody's going to know exactly if they're actually taking the drug, but knowing that prescribed is good. Knowing it was actually paid for is probably a step towards having better information. I'm not going to be corrected by the doctor on the call. Well, so how a drug, drug checker, drug allergy check works is it looks at what the ingredients are and it has a whole set of codes and it bounces off a whole another set of codes and it tells you whether or not there's an allergy or contraindication, right? So how would a doctor seeing a patient use an HIE to do that? We're not talking about, Kristen, if there was a different in the plan and I'm forgetting it, please correct me, but I don't think at this point we're talking about solving allergy, like alerting to potential allergy. It's more just giving the information about what medications the patient is taking. I think the EHRs have tools that do the other piece of work. I see. So just the reconciliation, are you on X? Are you on Y? Are you on Z? Kristen, am I speaking out of turn there? You're correct, yeah. Have you filled it? If not, the provider can initiate a conversation around that. They're different lifestyle factors that are at play just to dive deeper. But I think Dr. Merman wants to correct something here. Is that right? Oh, and if I just pop in for a question real quick. Yeah, yeah. Not at correction. I think that my impression of what you're asking Owen is what Beth is answering, which is that, you know, how a provider would use it from what that case scenario is, is, you know, what medications is my patient currently on, which is often a very hard question to answer, especially when these bed lists can be 10, they're 20 medications long. The question I was actually going to ask is my understanding there are proprietary like companies that do this, like SureScripts, I believe provides data that's fairly real time to EHRs to integrate to help with medication reconciliation. So if I could just ask the follow up question of, have we considered something like that as opposed to claims data to get more real time data and figured out if there's a use case scenario for that? Yeah, Kristen, I'm assuming I'm going to take this one. Yeah. Great. We absolutely have. And we in the past have that on old platforms. The challenge with that, with delivering that right now for us and we've been trying to deliver it, we have two concerns. One is the providers, the organizations that provide that data are stepping back from working with HIEs to provide that data and they're wanting to work with healthcare organizations and depend individually instead of on an HIE level. We're still trying to dig into whether we can change their minds and what that might look like. But I think it's a business model play for them. And when the services are available, they are very costly. And so, you know, if we can find a way through claims data or others to do it on a more cost efficient basis, I think was part of what we're trying to accomplish here. So are they, sorry, just one more question. So are they, how are they getting, they're getting the data directly from the pharmacies that then goes to SureScripts. And is there reporting requirements for pharmacies to give that data to SureScripts? I guess my follow-up, that's actually a leading question to a follow-up question, which is, could we have legislation to require pharmacies to give data to an HIE as they give data to SureScripts? Theoretically. Yeah, I mean, I think to your first question, I don't know that they're required. I think there are probably, I don't understand the full business model and I can absolutely get you an answer on that. It's not something I've explored. As far as the legislation, I think it's a great question, but we could consider. Sorry, Owen, thank you. That's fine. So, Miss Anderson, for the reconciliation, how it would work mechanically would be the doctor would then log into the HIE, pull up the med list from the HIE, and then read it off to the patient and check? Probably. Okay. Or were we doing the integration into EHR as a future? If they were to do that as opposed to using what data is in the EMR and it's only Medicaid data, would there be a risk that they'd have an incomplete record that they were using for the reconciliation? I think that's a good question. I think that's something we're going to have to carefully consider as we think about what we, integrating just, I don't mean in a bad way, just the Medicaid data, how we make that clear and communicate that in the portal. So there's an awareness of what limitations might exist on the data set. So it's conceivable the EMR would actually have a more complete data set because it wouldn't be limited to claims data or just Medicaid at this stage. I think traditionally the EMRs won't have what's actually been filled. So I think that's really the, it's not the, you know, it's not the prescribed. It's the what has the patient actually picked up, paid for and picked up at a pharmacy that we're all struggling with not having. But isn't that what the, I mean, I'm not a doctor, obviously Dave is, but isn't that why you do a reconciliation? You've asked the patient what they're on. So does it matter if they filled it or not? Cause that's why you're asking them. I don't know if that's a question for me or for for Beth, but I would say it matters a lot as to whether or not they filled it. It's pretty common to have a patient, to have a med on a med list that the patient hasn't filled for various reasons. One is they're uncomfortable taking the med to, they could be, they can't afford the med. They could get a med that was prescribed. That's, you know, a not a preferred med on their insurance lists. They don't like how the med makes them feel. So they decide not to take it. There's lots of reasons. So it is, it is really helpful to know what people are taking in the chat. And then, and I think what you're talking about is like, just because they filled it doesn't mean that they're taking it, but it kind of makes it more likely that they're taking it. So. Right. That's what you're asking them. Yeah. Yeah. I mean, and I'm sorry to continue on this, but I do think it's challenging because, you know, especially in my line of work, we ask these questions a lot, especially where I've worked previously where, you know, we didn't have as integrated of a healthcare system. So you get patients from multiple different hospitals and med lists aren't accurate. A lot of times people just don't have an accurate med list. They don't know the names of their medications. They take them. They don't know what they're for. You ask them, are you taken and they blood thinners and they say, yeah, I'm taken an anti-hypertensive. And so they don't know the classes of medications commonly some people do. And it's amazing and it's wonderful. But I would say it wouldn't be, it's not reliable. It's not entirely reliable. There's not really any entirely reliable way to determine what somebody's actually taking. But, but yeah. Thank you. The only two other questions. Is there any plan to get self-insured patient claims data? I think we're probably that's much further down the line. So I don't want to say like, no, shut the door, but also it's, it's so, so far down the line. It's too early to really come on. I get it. And then the data that Dr. Merman was talking about at page 14, the reductions in admission rates and such was, so the subject line is why pursue linking clinical and claims data and it cites these data points. And my question was whether or not those data points related to just using the HIE or whether it was the HIE plus using the comprehensive primary care program. It was the HIE plus the population health information. So let me restate that it was the clinical and claims data through the HIE plus the population health information. That's what those results were from. But I certainly will reach out to Deloitte to get more information on the overall study. So we all have that available to us. Deloitte to the study or what did they do? They were the ones who worked closely with the study. I don't know their exact role with it, but. Is there any financial incentive in this plan to incentivize providers to use the HIE platform? I'm pausing because I'm thinking through the different tracks and milestones and the incentive payments to actually use it. So like to send data to connect. So if we're talking about use as in terms of like sending production data connecting. Yes, there are incentive milestones around that. We did front end load the milestones because the program is a relatively short incentive program. So we want to encourage people to on board. Through the incentive payment structure. Okay. All right. Well, thank you everyone very, very much for answering our questions and presenting today. I'll open up to the healthcare advocate for any questions or comments they may have. We have no comments. Thank you, Sarah. Great. And then. Sorry, Eric, did you have anything? No, no, I just, yeah, Deloitte. Any public comment? Walter, how are you? Okay. Jessica. Dave, Jessica and Tom pretty much hurled my thunder already. So I'm not going to repeat that, but. I want to apply to real world situations that really happened. They go back before the digital age. And they're in another state. The first and concerned my late father who died in 1981. He wasn't terminally ill and he was in a hospital. Someone made the decision to throw him out of the hospital. The second one is. We were going through evaluations about my father's condition. He was terminally ill and he had. Some mental problems associated with the disease. There was an evaluation. Made by some analyzing. Physician or mental health specialist. Where they basically said this guy's too far gone. Don't even bother with them. That was in the pre digital age. I could not find out which hospital. CEO. Through my father out of the hospital. And which. Physician or counselor, whatever word you want to use for it. Wrote that evaluation. We could not get him into any nursing homes, any special health homes. Because of that evaluation, we finally were able to do it in the VA. We did that through another way. Here we are in 2023 in the digital age. I as a patient patients family. Could I go through all of these portals of all these acronyms. And find out who made those decisions. This is a real world application for all the theory we've been talking about today. Could I or could I not find out who made those decisions. And why. Through vital. Through patient record. I'm going to, I don't know the answer. We can miss Anderson. She has any insights might be helpful on this, but I'm going to assume the answer is no, given the historical lag and what data is actually in there now, whether those records got digitized. I'm just, I'm applying that situation to now. Let's just put it today. I just was just using that as an example. But now, I mean, now I, now I know. And it was in another state. It wasn't so. Yeah, I don't know if that'd be an HIE application. It might be an application you can find in the EMR by checking the audit log and seeing the notes on who did what when. And the audit logs are usually pretty detailed as to what action was taken on what date by whom. So I would think the answer to that would be yes, but probably more of an EMR function than an HIE function. I need to be a little mindful of times. We have another hearing. Is there any other public comment today. I was just going to add that it'd be great to work towards a system where there's centralized. There's a lot of personal health information, but a patient owns that information. And can it would be filed if there's an orthopedic file, whatever mental health and and what has to do with reproduction, whatever, but as well as they go between providers. It would pretty much allow access by code to that medical information. It wouldn't stop every place that a person goes to receive medical care to have because that's going to go on. But the communication between provider groups is what is troubling and to rely on a patient to just fill out on a paper form before they get into the next provider. All of that information just the med list alone is too much to ask of a patient using their mental, you know, where they are mentally. If it was all protected within one location and then keys delivered to places that they go for medical care. That seems to me to be that sustainable future for wherever we are in the country to. So if there's if there's folders, we don't have to get or anything that has to do with our sexuality to somebody unless we give them that key. So it's it's patient ownership of the medical records. And then it likewise would help answer Walter's questions and, you know, his family could have access to the key and and know everything that he wants to know. Thank you. Any other public comment? Okay. Miss McClure and Miss Anderson everyone. Thank you very much. We'll let you go and we'll take a quick. 5 minute break and come back for vitalize. Thank you. Susan was the core person Claudine. That's what I was told. I can double check with Kristen. Hold on. We'll try to get to the bottom of this. Sorry about that. She's here. She just texted. So, but I don't hear. I don't hear her responding. Maybe she can't hear us. Okay, let's try this one. Can you hear me now? Oh, there we go. Yes. Okay. My apologies. I was answering you didn't realize you couldn't hear me. No, that's great. Just want to make sure you're here. Thank you. Okay. So we'll, we'll resume the hearing and go on the record. The next agenda item is the vitalize ACO presentation. I have one quick housekeeping note. I have to leave by 410 for an appointment for my daughter. We went a little long this earlier session. So if I have to leave and we're not done, I'm going to turn it over to member homes to conduct the rest of the hearing. So I apologize for that. I didn't anticipate would go so long earlier. And with that, I'll turn it to Michelle Sawyer. Thank you chair foster. Let me share my screen. All right. So I'm Michelle Sawyer health policy project director here with the Green Mountain care board. I am here to introduce vitalize health nine ACO. This is the first year they've come before the board to present their budget. So this should look pretty familiar to a lot of folks. But let's look at this just to orient ourselves in the Vermont regulatory process as it pertains to finalize. So over on the left, we have ACOs that accept payments from Medicaid or commercial insurance payers. You can see that certification is a requirement of these ACOs. On the right, we have ACOs that only accept payments from Medicare because vitalize health nine is a Medicare only ACO. They are not subject to the certification process. And they are only going through the budget review vitalize health nine does have fewer than 10,000 attributed lives in Vermont. So the review is based on the standards and processes that the GMC be deems appropriate. Whereas larger larger ACOs would be subject to all standards and processes established by rule five. Finally, in the bottom box, the Green Mountain care board has developed Medicare only guidance for these types of ACOs with fewer than 10,000 lives. And this guidance is the basis for the review. The slide outlines the budget review process as outlined in statute in deciding whether to approve or modify the proposed budget of an ACO projected to have fewer than 10,000 attributed lives in Vermont during the next budget year. The board will take into consideration one any benchmarks established under section 5.402 of this rule. Those criteria listed in 18 VSA 93 82 be one that the board deems appropriate to the ACO size and scope, which we will we will review shortly. Three, the elements of the ACO's payer specific programs and any applicable requirements of 18 VSA 9551 or the Vermont all payer accountable care organization model agreement between the state of Vermont and CMS. And any other issues at the discretion of the board. The staff recommends that the board consider the following factors from 18 VSA 93 82 be one. Information regarding the utilization of the health care services delivered by health care providers participating in the ACO and the effects of care models on appropriate utilization, including the provision of innovative services. The character competence physical responsibility and soundness of the ACO and its principles. Any reports from professional review organizations. The ACO's efforts to prevent duplication of high quality services being provided efficiently and effectively by existing community based providers in the same geographic area. As well as integration efforts within the blueprint for health and its regional care collaboratives. Continuing the, the staff recommends the board consider public comment and all aspects of the ACO's costs and use and on the ACO's proposed budget. Information gathered from meetings with the ACO to review and discuss its proposed budget for the forthcoming fiscal year. Information on the ACO's administrative costs as defined by the board. The extent to which the ACO makes its costs transparent and easy to understand so that patients are aware of the costs of the health care services they receive. And the extent to which the ACO provides resources to primary care practices. To ensure that care coordination and community services such as mental health and substance use disorder counseling that are provided by community health teams. Are available to patients without imposing unreasonable burdens on primary care positions or providers or on ACO member organizations. So these factors were chosen based upon the size of vitalize presence in Vermont and the scope of their ACO. They have a very limited presence in Vermont as they only have two network providers and a very small number of attributed Vermont beneficiaries. This slide is just a quick reminder of the timeline vitalize sent us their budget on November 1st. We're here today to hear their to witness their hearing. The GMCB staff will present their analysis next Monday on November 20th. And there is a potential vote scheduled for December 6. As always, the board welcomes public comment on all of the proceedings. The deadlines listed here will allow the board to consider public comment ahead of each upcoming event. And here is the agenda for today. We just went through the criteria and I will hand it over to vitalize to start their presentation. We'll review some staff questions. We'll go to board questions. The health care advocate will have an opportunity to ask questions. There will be an opportunity for public comment. And if necessary, we do have an executive session set up. So, I will stop sharing and hand it back to you, chair Foster. Thank you. I'll just turn it over to Mr. McCracken to swear in the witnesses and then to the vitalize folks for their presentation and thank you for coming here and we're excited to hear from you. Thanks, chair Foster for the vitalize team. Who's going to be presenting or answering questions today. It's going to be 3 of us Amir on the jar Kevin Murphy and John Toronto. Great. Thank you. I feel raise your right hands. I'll swear you in. Do you solemnly swear that the evidence you shall give relative to the cause no under consideration shall be the whole truth and nothing but the truth to help you God. I do. Thanks very much and I'll turn it over to you for the presentation. Thank you. Good afternoon, everyone. My name is Amir on the jar. I'm an internal medicine physician by training and one of the co-founders and chief medical officer here at vitalize health. Pleasure to be here and thank you for giving us the time today. Next slide. A little bit of background about our, you know, our ACO reach entity that we've named ACO nine. This year 2023 is our first performance here results are not out yet for this year. I hope we're looking to get those in October of next year. We are a standard ACO reach, not a high needs and we're doing a global risk. We're taking primary care capitation. But our physicians and groups are able to continue to build a standard fee for service. We have roughly around 180,000 lives in this entity. It's our main entity. 2000 of those lives are in the Vermont and they're spread amongst to FQHC's Little Rivers healthcare and mountain community health. So we're here to talk about. A little bit of background about vitalize health. So vitalize health, you know, we initially started as primary care practices, home based for the seniors, Medicare focused. You know, as an intern is seeing things in the healthcare landscape realize there's a lot to be desired. And some of the sickest patients they need a little bit more hand holding than your average, let's say Medicare patient. We've developed, you know, practices, you know, we would send nurse practitioners to the home, wrap around care 24 seven access and consistent engagement and we would see the sickest of the sick. And after doing that for several years, we actually joined our own, we joined an ACO in 2018, where we joined an ACO. And our practices that we started from scratch did really well, you know, and from a savings perspective. And that's when we decided to make a shift instead of just building practices partnering with existing practices, medical centers in order to, you know, help instill some of this know how and value based care. And 2019 was the first year we actually created our own ACO in 2019. And then we've been expanding ever since then. You know, and currently I believe we're, you know, in many markets and we have over 250,000 attributed lives between all our entities in several states. A lot of what we do is, you know, a lot of what we do is take the things that have been proven in healthcare that have been proven to work, but just don't seem to get done frequently. Like a perfect example is, you know, transitions of care, you know, everyone knows that patients should be seen in a short period after they've been hospitalized or in a SNF by their PCP. But when we look, it happens less than half the time within two weeks. And what we realize is, you know, when we work with a lot of our independent PCPs, that's who the majority of our practices are independent mom and pop PCP practices, FQHCs. What we realize is sometimes they have a lot of little problems that are preventing them from sort of getting these good practice hygiene things. They may not have data. They may not have staff. They may not have know how to do certain things. They may not have timely data. So we work with practices pretty closely to, you know, bring that know how and that information to them so they're able to act on it. You know, so we look at ourselves as, you know, physician enablement, you know, we're here to enable providers and physicians to transition them from value, from fee for service to value based care by meeting them where they're at. From a unit, you know, from a unit level perspective, you know, we break up our ACOs into medical units. Each medical unit has a primary care doc with a value based care background that works one on one with physicians. We do one on one Zoom meetings where we talk about the most pertinent data, things that may need to be addressed. And that physician-to-physician relationship we've found to be, you know, very conducive to help transition from this fee for service mindset to more of a value based holistic mindset. You know, my partner John will talk more about our care model and how we do things in particular. But let's a little bit of background on who we were last year was our first year as an ACO reach. Last year it was called actually DCE, Direct Contracting Entity. They had a name change. And we were proud to say we were one of five DCEs last year where we were in the top quartile, not just for cost reduction, but also for quality and patient experience, which are really important, you know, aspects of the triple aim as well. You know, we hope to continue to, you know, improve things bit by bit. And we realize healthcare has a million little problems. And we're trying to solve as many of these little problems one by one with our practice partners. And, you know, and, you know, even though we feel confident that we know a lot, we still also confident that we don't know everything. And we're always here to learn from our community members, practice members and patients because, you know, this is a, we believe it's a team approach. It's not a, you know, single individual approach. Next slide. Pass it off to you, John, if you don't mind. Thank you, Amir. I appreciate it. Thanks for having me. My name is John Toronto, a family physician, executive vice president and national medical director here at Vitalize Health. I want to spend a little bit of time talking about our model of care. You can see what sort of what we do. I want to talk a little bit about how we do it and our approach. We think about our care model really in four quadrants. Access being one, if not the most important, super important. We also think about clinical documentation. It's important for chart accuracy as well as making sure that our analytics work right in terms of having complete and accurate documentation. We never get far from quality and we always think about utilization. So how do we do that? We are doing our level best to move the healthcare system as much as possible from reactive to proactive. That starts with prevention. That starts with annual wellness visits. So that's one of the first things that we work on with our practices, in particular our community health centers, where most folks in the United States, most Medicare beneficiaries do not get an annual wellness visit. And it's probably lower than average within community health centers for lots of different reasons. Not that they don't provide excellent care. It's just that it is an extra. The visit requires a little extra work and really some workflow changes. So that's part of what we do when we come to a practice. We bring a level of expertise that helps them with the workflow. So starting with annual wellness visits again, making sure that all of our seniors get screened for falls beyond the screening as I think it was Tom who mentioned something earlier in your previous hearing. It's not enough to screen and I'll use falls as an example. We would screen for falls at the same time before we even started that we would work with the practice to identify what are they going to do with their folks who are high risk for falls. So identified local resources be that a hospital, perhaps with a PT and OT or senior senior center or other that has a matter of matter of balance or some other evidence based approach for falls risk. So thinking even before we start end to end when we do actually screen we can intervene and then again we say make sure that it's seen. So that is actually part of our process as we start with our annual wellness visits. The other key piece of again access is really thinking about catching patients when they come out of a hospital to Amir's point, making sure that again we have the HIV feeds, the ADT feeds when possible. The staff knows exactly how they're going to use those. They save spots again for those transition of care management visits. Again, we help them template those so they again are providing high value. Again, not interesting conversation earlier. Med reconciliation is a huge driver of that making sure that we get a good med rec and I'll talk a little bit about how we support the practices in the transitions as well as we go forward. Additionally, we will do our level best to create an ED diversion program for our practices again whenever possible. If a patient calls and needs to be seen they can they can be seen. So again saving space for that and then of course within the reach we also follow up all of our patients who go to the emergency room for any reason. So you have to have some capacity beyond your sort of day to day to see all your annual wellness visits to create the access for your annual wellness visits and for your follow ups and for ED diversion. So we work with the practices based on their numbers and help them understand what that will look like how they can build their schedule and their template to be successful in that model. So HCC is part and parcel of the training. We focus really on the on the most basic and key elements of HCC. We're not folks who are out there trying to run up the score. We don't spend a lot of time. If you have experienced this. We don't talk about senile perpura. We really focus on making sure that we're getting depression right that we're getting our diabetes right. We think about vascular disease the nuts and bolts of family of family medicine or primary care to make sure that we're actually just doing doing the basics and getting those right because that's such a huge opportunity alone. So that's part of our HCC quality in the ACO reaches really claims based. So it's a function of all cause readmissions unplanned admissions follow up from exacerbations and patient experience. So we obviously focus on all of those. Additionally we also work to present care gaps at the point of care so practices can close gaps for colon cancer screening breast cancer screening also better management of blood pressure better management of diabetes. And along the line we'll get to the point where we can help also with medication adherence. Again all of these things are have been shown to drive down the total cost of care. So even though they're not in our model and I'm air quoting they're not in our model. They're still very much part of our clinical model. And then we we finish with utilization and the way we do utilization again is we. You know that primary care gets about five cents or five percent of the of the Medicare dollar. The rest of that goes outside to the hospital to the specialist. So we work with our local practices to identify high value providers and these folks are have been proven within the data to have high quality and lower costs. And whenever possible drive patients to those to those individuals in I'm going to guess that for our health centers in Vermont they will have limited access to different specialists. So what we will do in that case is actually work with a specialist they're working with and see if we can help those specialists actually continue to get the outcomes that we would anticipate as as a deemed high value provider if you will. And then last but not least on the utilization is that we drive what we call select patient visits. And this is where we look at are probably top five to seven and a half percent of Medicare beneficiaries who typically have at least two co-morbid conditions beyond beyond the sort of hypertension and osteoarthritis. These these are folks with diabetes and heart failure diabetes and COPD as an example. And then do our level best to drive a level of primary care or even specially care touches so those patients frequently are frequently seen in the outpatient setting. The evidence suggests that when you do that you can drive down the total cost of care. So that's the sort of big big picture when you think about what we're trying to do on the day to day is is our our model really relies on the five m's of. Of geriatrics which is really focusing on the mind mobility medications the more multiplicity of chronic diseases. And then last but not least what matters most so advanced care planning is a big part of what we do as well. I'll turn it over. Yes. Thank you. Dr. Toronto. Can everyone hear me OK. Good. So and hard to ask to follow my my esteemed colleagues articulate how we actually look after patients and you'll see a little bit here how we also look after the physicians that we work closely with and partner with. Even though it's just a simple table of numbers and the business model is is simpler than it seems when you get down to the numbers and I'll try to address. There were some questions sent in advance as I walk you from top to bottom taking just a moment to do so. The the second number which actually is mislabeled as a dollar sign is a number of lives in Vermont. That's our current number of 2005 patients to the two practices that have been discussed. To put this in context this is a you know it is a modest portion of AC09 but we actually treat every practice as an individual set of physicians and patients to work with closely. We assign folks to works with each of those practices to help them generate results in a value based care setting really making folks better. The end result of that is generating savings which we share with the practices as you'll see in a second when you want to talk about what is the revenue and how the numbers and shareings with the physicians work. You take those 2005 lives and multiply them by the first number that 15500 per year benchmark comes from CMS. We have you can see it's a nice round number. We have slightly discounted that to be conservative. That's more or less provided to us for AC09 as a whole. So it is to answer the question directly a nationwide average figure. It is not a Vermont specific figure. We're not we're not afforded that level of detail yet. And either there are regional adjustments and other things that happen over the course of the year. The specificity down to the practice level is something that is is pretty fuzzy in the data that comes from CMS. So it's typically starting with especially before the years begun with this national benchmark. And as I said we've rounded down to be cautious and not overpromise even to ourselves. So 15 five times 2000 gets us to a little more than 31 million in revenue just for the Vermont component of AC09 which is a over about over half of our business for 2024. The estimated medical expenses that really is the complement if you will of what we estimate as a 6% savings rate. So we believe based on our past experience and we've got a I will tell you a rigorous methodology and actually really a shared savings committee populated by some of the most senior folks in the company to determine what levels of savings by region and by entity that we believe are achievable for the coming year we need to set an estimate and that's actually for the first several months of the year how we record for bookkeeping and accounting purposes as the data on claims as I'm sure everyone here is familiar happened with a lag over the course of the year. So during that lag period we're living in the world of estimates for AC09 our estimate for savings for 2024 is 6% of benchmark 1 minus 6% leads to 292009 million 200,000 roughly of medical expenses. The remainder we then take 40% it's about 1.8 million we take 40% of that and distribute that to the PCPs. A moment on how that's just how and when that's distributed part of vitalizes attractiveness to working with partner physicians is that we take a significant portion of that estimated savings which isn't paid out in full typically until as Dr. Alan Jar referred to October of 2025. So we didn't want to have our physicians who were doing the work wait that long, which is a dilemma in the ACO realm. And we actually have a program by which based on their activity consistent with value based care which we measure constantly and support them in so doing in numerous ways some of many of which have been described. We pay them in advance monthly some portion sometimes it's actually more than half of the anticipated savings and the remainder is chewed up in that October 25 ultimate payment but finalize is raising capital and and doing other things to fund that payment to the doctors in the interim. We are well capitalized. We have great capital partners. We've grown very rapidly as a result of all of those things and doctors have stayed with us with relatively almost less than marginal turnover due to the that relationship that we build both financially and otherwise. But you can see that would be for these two practices at roughly three quarters of a million dollars paid over that, you know, slightly more than one and a half year period, the bulk of it upfront. What we've done to have a reasonable P&L and say what is the profitability at the end of the day of this component of our business the Vermont region if we isolated as such is a million dollars we did put in. And you can call this a good estimate a placeholder for general administrative expenses and it's labeled legal that we can identify a ballpark of $50,000 of legal expenses that would relate specifically to our business in Vermont. I will tell you that or what you're seeing here is that we do not conceptually at least we do not allocate our overhead, you know, and the expense of folks like the executives who are on the phone on this call to each individual region, sub region entity in that way. So we have an effort really at vitalize to run the business nationwide and would only see a very modest amount of expenses that would actually be allocable to Vermont specifically. So that leaves us with a million dollars of profits on 31 million of revenue. Very simple P&L. Thank you. Sorry, did you have any staff questions you want to ask. Yes, thank you. Let me pull them up, please. My first question I was curious if file is health staff have yet attended a blueprint for health orientation it was something that you had actually mentioned in the narrative submission blueprint for health as a has been around in Vermont for a long time, and most of our providers are deeply entrenched in the work and we're curious if you've had the chance to orient yourself and go through kind of their onboarding that they offer through their department. We have not we were working on that. Great. I'm glad to hear that. Wonderful. Another question I was curious about. There had been a series of metrics that had been a part of the appendices and we had asked vitalize for their feedback about what it would take for vitalize to report their performance on the specific metrics going forward. And that was that wasn't addressed in the submission so I was curious if you might be able to speak to that today. Yes ma'am it'll take us about two weeks to create that data set once we have our claims data we can do that. Okay, wonderful. Thank you. Another question I had. Mr Murphy you were describing how how the ACO provides providers these these shared savings in advance so they don't have to wait, you know, 1820 months to see any potential shared savings. I was curious what it would look like for the provider having received all of these payments over the course of time and it turns out there happens to be a shared loss. Do they have to return those funds to the ACO? Short answer is no or not necessarily our contracts the way they're written Michelle is that if there were you know errors or overpayments there may be a right to claw back a portion or all of those overpayments in the following year as a credit against savings earned. We've not historically and to date we've not exercised that so in two ways doctors benefit by working with Vitalize which is one we carry all of the downside risk at Vitalize should there be a lost circumstance. Two is again at least historically we've not sought recovery for payments made I would say that it's our experience is that that has occurred in only a marginal way thus far. Okay, thank you. Let's see. I was curious about the health equity plan. And it sounded in your narrative like its implementation might be kind of an iterative process you might start it at a small, a small number of kind of network providers. I was curious if you had an idea of when that plan might be applied in Vermont. We would take that we plan to take that plan national nationally in 2024 so next year. Wonderful. Wonderful. That's all of my questions. Thank you. Thank you very much. I said a couple real quick ones. How many states are you operating in? We're currently in 36 I believe if not 38. Okay. I'm glad you're here. It's great to have other ACOs here. Why, why Vermont? Actually, I think we're here because we're working with two community health centers. We work with multiple community health centers across the country. I am actually a former physician from a community health center so I'm biased but I will still give you my pitch on why community health centers work so well in the value based healthcare space. Medicare lives are growing in that space. They tend to be Medicare beneficiaries managed by community health centers tend to be sicker and lower cost. So the opportunity is there for community health centers again to take advantage of the value they're creating within the system. The other thing I'll tell you the chair fosters that we also with our prepayment program again driving the what we call our vital signs is another way to put to help health centers maintain a cash flow. Additionally, we have them do annual wellness visits that pay more than a typical visit. So we are, we are very bullish on community health centers. So why, why Vermont? It's those two community health centers. You got them as to sign up and then that drove you coming to Vermont. Yes, yes. I see. And then the benchmark on the PO, he said it's a national benchmark for her capital spending for Medicare. Is that what it was? Yes. The 15,000. That's correct. So Vermont is very low on our Medicare spend. Does that increase the likelihood of achieving savings? The fact that there's a national benchmark but we're a very low Medicare cost state. The national benchmark will be an advantage to our main participants. Okay. I didn't have any other questions. I'll open up to the other board members and thank you all. This is Dave Merman. I'm an emergency physician. Different kind of physician than you folks work in different environments, but appreciate the work you do. I appreciate you being here. Can I just follow up one question on chair Foster's question? So it's shared savings compared to the national benchmark is what is how the shared savings is calculated or is that how the shared savings is calculated for the community health centers here in Vermont? Correct. Typically it's a pool. It's part of the pool. Yes. Okay. And the only other question I have for you is one that I just, it's sort of a nonspecific question, but we sure talk about value a lot in our activities on the Green Mountain Care Board. And I've come to realize that there's a very broad set of definitions of value. So this is kind of a fluffy question to you all, but how do you, when you think of value use the term value, what do you mean by value when you're talking about health care? What I mean when I say that is I'm talking about a patient experience or an episode of care that is high quality and low cost. That's value to me. You know, and our general sort of the way we operate is try to improve the relationships amongst providers and patients. You know, we incentivize the providers with these upfront incentives to bring in an additional resources to help better support patients, help maybe even stuff up. But a lot of what we see is, you know, we're successful when patients have a better relationship with their providers. And a lot of what we see is, you know, as John alluded to earlier is reactive care schedules filled up based off who's calling, not based off who needs to be seen. So that's what we bring in. We try to improve the workflows amongst our practices is, you know, we may understand that Mr. Smith isn't calling asking for appointments every day, but hey, you know, the data that we have suggests that she would benefit from extra touch points with her PCP. And that's a lot of what we do is try to bring a more holistic and not let patients fall through cracks that they typically do in a fee for service model. And a lot of it is driven to just improving relationships amongst providers and patients. Thank you. That's all I, all I have passed the torch to whoever's next torch passing here. Well, thanks for coming. Always interesting to see new models and new approaches to trying to improve population health and save costs. I have just a couple of questions. One is what criteria do you use to select providers for inclusion in your ACO? So can any community health center join or are there things that you're looking at in particular data that you use to select providers in your network? I could take this one. Yeah. So, you know, we look at a couple of things. The most important being is engagement. So our model doesn't work if the provider group that we contract with is not meeting us halfway, not agreeing to meet with us. So it's mainly effort. So what we typically do is actually prior to signing up a practice in that August deadline, the prior year, and the prior year, we try to work with them for a few months prior to that deadline, setting up our touch points with our medical directors. And a lot of it is effort-based. We're not looking at people based off, you know, what we think their share savings could be. We're not looking at number metrics. We're looking at engagement effort. Are they, you know, even if they're been historically a poor practice, but they're meeting us, they're engaging, it's all we want, you know, is effort. One other metric we do look at is attribution. If a practice has seven Medicare lives, it's probably not going to be enough of their panel to be exciting and to get that engagement and the sort of the first criteria. So, but overall it's engagement and you could argue that attribution size is part of that engagement. You mentioned something. I think Dr. Toronto mentioned this in the presentation, but I also saw it in the submission. And it was a description of we leveraged data and analytics to identify the highest performing providers in the historical primary care referral region and then engage our PC practices in the selection of providers. So, a couple of questions there. What data are you using to measure provider performance in specific? Where do you get that data? And what is the data that you're measuring specifically about cost and then quality? And then what exactly does it mean to engage the PC practices in the selection of providers? Is it creating a network, a narrow network? Are you, I'd like to understand what you're thinking about with respect to those referrals to specialists and hospitals to identify and then steer patients towards high performers. Yeah, we use a third party platform that uses historical Medicare data. That's a care journey actually is the name of the company. So it's not too old that and then we use through their tools and our analysis. We can actually then determine how we rank our specialist in any given area by total cost of care costs per episode plus quality measures that are built into that into that data set. Quality measures. I guess I would be curious as to there's such a range of how we measure quality. So what, how do you measure quality in that data set? You know, I'd have to, I'd have to come back to you and give you an example. It would be different. Cardiology quality would be different than orthopedic quality as an example. But we can, we can get those get that and bring it back to you. Absolutely. Yeah, I'd be very curious about the data. And then what does it mean to engage the practice in the selection of what providers to use? So we work again, as Amir alluded to, we work every month with our practices. So part of one of our exercises would then be to say, let's look at the folks that we've identified as high value providers, the folks that you're already using. That's great. Let's continue to make sure that your patients continue to go there, right? Knowing that the control within the Medicare population is kind of, you don't have that much control. They can do whatever they want. But when you do make a referral, make a referral to a high value provider, they also might see folks on our list. They say, yeah, but for instance, that person's not taking new patients. We can't see that in the data. So then we would remove it or the numbers are small enough that they'd say, but I really like Dr. Jones over here in which case we would say, okay, let's figure out how we can make sure that Dr. Jones is also sort of eligible for that criteria. That being said, to your point about data, once we start getting our claims data, we can actually then continue to verify whether or not our specialists who are our high value providers who are under contract with us to work as high value providers are actually meeting their measures. And to just emphasize, whenever we get the data, we always talk to our PCP practices and a lot of times, over 90% of the time they're in agreement, the data and what our PCPs in the market say, which we find that to be very interesting that they already sort of know. And as John said to stress, we don't have the ability to narrow any network, any of our patients could go anywhere. For us, it's just the way I think about it, if my mom was going to go see an orthopod, I'd probably ask a few PCPs, who do they recommend? Maybe look at some data that I could find. It's exactly what we're doing, having this conversation. And ultimately, most of the specialists we come across are great, but there are some markets sometimes where we find specialists that are over utilizing healthcare services, strictly part of the fee for service game. And those are some of the things that we're hoping to weed out low value care is a big sort of item that we try to tackle. Fantastic. Okay, thank you. Good afternoon and thanks for coming and sharing more information about your model with us. I think it's great that you've chosen to come to Vermont. I think it's a great opportunity for us to see your approach. And it's very easy to get caught up with alternative payment models and be very concerned about risk. And what I have seen listening to you and reading what you shared with us is you look at things through a lens of opportunity and recognizing that working with even patients who are currently very sick. And panels of patients who are very sick. That's where the greatest opportunity is. And so I'm glad you're here and look forward to seeing how you do. Thank you very much. Appreciate that. Hi, thanks very much for joining us. I'm Robin lunch, but on the board for about seven years. So welcome. I did have a couple of questions. So when you, so you, you mentioned several initiatives that you look at to work with your providers to ensure, for example, folks are getting their annual wellness visits, post discharge, follow up, etc. When you do you do any baseline data analytics to see are those like big issues with that practice, not really issues with that practice, or do you just kind of assume that everybody can improve there? I'm just wondering how tailored it is to that those programs are how tailored they are to the practices participating. Yeah, the data set I alluded to earlier, we actually use that to determine prior performance. So as we're engaging practices prior to the performance year, we have an idea of where they are. Absolutely. We do believe in things that are just good practice hygiene. So regardless of previous performance, we want everyone to do a wellness exam. We want everyone that's been discharged to be seen. But absolutely, you know, we may see that a practice may struggle more with readmissions and their transitions to care numbers are low. So we may prioritize that first before we do, you know, some other initiative based off their benchmark data. Absolutely. Great. And it sounds like part of your engagement with the practices can get really into the nitty gritty of things like workflow. Is that did I catch that correctly? Yeah, we have a whole team that works on workflow. And then that's sort of our population health associates that do honestly workflow and focus on the metrics. Our medical directors are more about collaborating and really try to focus on the clinical model or even individual patient care where there's opportunity to improve an outcome based on guideline directed therapy as an example. Great. Thank you. And then, lastly, I wanted to just, I guess I had two questions, but one question was around that health equity plan. It sounds like you have to have an approved health equity plan as part of this particular CMS model. I'm wondering what the status is of your health equity plan. And if that's something that you're able to share. You want to take this John or? Yeah, I'm here. I'm not sure I know where it is. Last I heard. So, yeah, I'll give that to you. Sorry. Yeah, we could definitely get back to you for more information in 2023. The health equity item that we started to work on is food insecurity. So as approved by CMS, they had us choose certain markets, certain zip codes for a pilot for food insecurity. We're working with the local CBOs and trying to identify patients in a handful of zip codes that CMS approved for us. So that's what we're doing in 23 is around food insecurity, working with food banks, you know, God's love in New York and different food banks, because we see that, you know, obviously food insecurity is directly linked to hospitalization, especially for certain diagnoses like diabetes and CHF and so forth. But that's been our focus. We're also going to be focused on top of that is transportation as well. Making sure patients are able to get rides to PCPs or specialists or so that way they don't fall through the cracks. But we'll get more information about the exact plan for. It's been approved. It's been approved, Robin, just a friend just phoned me and let me know. So yes. Call a friend is great, you know. Yeah, great. If that's something that you'd share, I'd love to learn more about what you're going to be focusing on in 2024. I think, you know, we have a lot of community oriented, social oriented programs. So I think in going back to the statutory criteria and sharing that there's not duplication and that it's additive, I think is an important consideration. That's a really important point. Sorry. That is actually always our approach. We never come in and say, hey, we have a model. Let's throw it down. We always look to see where we can apply, where there are opportunities to bolster something that's already there as opposed to rip and replace. Great. And then lastly, I met in your submission. I did see a reference to potentially promoting in home care and it wasn't clear to me whether if that was services that someone needed. If that's something that you contract with a provider to do, if that's something you have employees who do or exactly how that works. Yeah. And maybe it works differently in different places. Yeah. So absolutely. So we, you know, sometimes we come across physicians, you know, where we may flag a patient that may need to be seen and their responses. Hey, well, they're not coming into the clinic. You know, I don't do house calls. Like, what do you want me to do about it type of deal? So we've developed a home based practice. You know, we call it our priority care program where we send NPs to the home on behalf. We're not trying to replace the PCPs. We don't want to be the PCP, but in certain rare cases for that one, two percent of patients that may not be able to come in but need to be seen. We send NPs to the home. Right now it's mainly in New York, New Jersey. You know, the fact that we've spread pretty quickly in the last few years to 36 states. You know, one of the things that we are exploring is, you know, maybe we should partner with certain groups in certain markets. As of right now, we're not quite right there for Vermont due to the, you know, the geography and the low attribution, you know, to have those resources. But it's something that we're always open and looking for because we really are big believers in home care. And, you know, some patients are just not able to see their doctor and it doesn't mean that they get ignored and just go to the hospital when things flare up. Sure. That's great. I was curious about it because it seems like in 36 states, you're probably dealing with 36 different licensure issues. And as well as in this state, we have some, we have some designation issues where certain entities or the entity that can provide the services. So I was just curious if that was something you'd started tackling here or not. So thank you. I think that covers my questions. So thank you very much. Could I just ask one more quick question, Chair Foster? Yes. So just curious. I'm not particularly familiar with these practices. But I think I saw in the submission that there was 23 providers at one practice and 29 providers listed at another practice, but only 2000 attributed Medicare lives. Are there, are these all the Medicare lives from these practices or are there selected Medicare lives from these practices? We will manage all that are attributed to us. It's about 20% for both of those practices are Medicare beneficiaries. The other 80% are others. So that's why you see that large number of providers for a small number of patients. They're comprehensive clinics, so they cover a lot more lives than just the Medicare lives. Okay. That's it. Thanks. Okay. Anything from the healthcare advocate? Yes. Sorry. A little bit slow. Good afternoon. Just a couple of questions. Stand by health policy analyst with the Vermont office of the healthcare advocate. Just thank you to vitalize and the board for all your work on this just for vitalizing. I know you're new. We're a consumer advocate. So a number of our questions are going to reflect a consumer protection lens. So my first question, you talked a bit about this in your responses on page seven where you talked about your model of care. You said you encourage providers to take a more active role in their patient's health care and this aligns with what you said on your website where you compare what a typical ACO does with what you do. And one of the things that's different, I think you make a distinction that you do a lot of data analysis. And I'm wondering what type of data that do you provide? What kind of analysis do you do that a primary care doctor wouldn't already have access to or is in addition to what they do already? It typically, it's really more about utilization that's happening outside the walls of their practice. Most folks know exactly what's happening for that, you know, 15 minutes times three or four in a year. But most of the health care that's delivered to that patient happens outside. So we would surface folks who are utilizing services that perhaps based on their the acuity or their their actually disease burden may or may not need or they're just using like. So we spend time talking about folks who spend a lot of time in the emergency room as an example. A lot of times practices aren't aware that that's happening. Sometimes they know sometimes they don't. It could also be someone who's using a cardiologist frequently. I've seen doing this work where there was a patient who saw a nephrologist 52 times in a year every week and not for dialysis. So that's the kind of that's the kind of information that the primary care providers do not see if they don't without access to claim status. Yeah. And to add to that, you know, it's it's flagging things that they don't see patients, you know, we call it proactive scheduling instead of reactive scheduling. It's like, you know, these are patients you should really engage to bring in because there's a need, whether there's discharge or there's a, you know, some condition that they may be struggling with. But and and then while they're in the office is giving them certain open items, they may not be aware that this patient needs a colonoscopy. They may not be aware that there is some type of, you know, medication management that could be improved. You know, we also see a lot of physicians sometimes, you know, their level of experience ends with the residency, you know, their knowledge base and things get changed. You know, struck to know that medical information from a publication studies on PubMed doubles every 73 days. So the amount of physicians keeping up with all the new stuff is not it's not a big amount of them. So, you know, we see physicians who have patients on one therapy for COPD, even those data and studies show they would benefit from dual therapy. So things like that were also able to flag and it's a conversation. They're ultimately the decision maker. It's their patient where we just pull up the study doctor to conversation. Hey, you know, there was a study in 2011 that said patients would COPD benefit on two inhalers versus one share the study. And a lot of times it creates an aha moment for the PCP. Well, they're like, interesting. Thank you. And it gets done. So that's another reason, you know, why this is helpful. Got it. Thank you. On a different tax, I did notice that several individuals online on Google reviews submitted some negative reviews, you know, alleging that your company is a scam. You sent accepted mailings and I know you responded to a number of these and said we take these reports seriously and are taking appropriate action. I wonder if you could just speak to those reviews and what actions you took in response. Yeah. So what ended up happening there is cyber hacking. What happened is people part of identity theft scheme, they would reach out to candidates on LinkedIn pretending to be vitalized health. They would set up an interview. It wasn't a vitalized health employee. It was a third. We don't know. We filed a complaint. I don't know what happened with the investigation. But groups were posing to be vitalized health HR members recruiting. They would send fake job offers out and their goal as part of the job offers to get these candidates to submit back their name, social security, date of birth, home address. So it was a cyber identity. So that's why people started saying it's a scam because, you know, once they submit that information, they wouldn't hear from us. And they would reach out to us and we'd be like, what are you talking about? We weren't interviewing you or anyone. So it was unfortunately identity theft cyber scam that we were, you know, victimized by. Got it. Sorry to hear about that. Thank you. And I apologize for the doc in the background. In February this year, it was reported out that you secured $100 million in venture series seed funding from private equity firms. I'm wondering how you feel about in general, and if you can address the role of private equity investment in primary care and whether or not you feel like it improves health outcomes. I mean, our office is particularly concerned with affordability and access. And I'm sure you aware there have been some critical articles about the role of private equity in that space. I'm wondering if you could speak to that. Absolutely. I'd love to. So, you know, a lot of private equity or just investment groups have gotten a better up in health care. Because if you think about it, if you, you know, I know this happened a lot with the SNPs where a lot of private equity owned skilled nursing facilities. If you're operating in a fee for service landscape, you know, my opinion, not necessarily the company's opinion is I think private equity isn't necessarily the best thing because if you're just trying to squeeze the bottom line in a fee for service world. How do you do that? You cut resources and you maybe do more care that's not needed. You know, our model being in value based care, you know, we're outside of that fee for service model. We generate savings. You know, if you think about the way we generate our money, all our revenues through or our, you know, profit is through shared savings. And we have no ability to restrict care. We have no ability to change, you know, how provider groups operate, you know, on the downstream network. So having actually private equity funding is actually a benefit for us because it enables us to go in to these FQHCs or to these small mom and pop PCPs and front the millions of dollars of upfront incentives so they could hire that extra MA to call the sick patients to be brought in. So they could bring in the extra NP to, you know, have extra bandwidth to see those patients that need to be seen urgently that day. That's how we leverage our private equity money. So I personally think I don't think it's a question is private equity bad or not. I think it's a question of more along the lines of fee for service and value based care. You know, personally really view value based care is the most equitable and probably best government program we've seen to actually address the problem. We have no ability to limit any care. Any of our patients could go anywhere, see any doctor get any medication yet we're on the hook for the cost. So what we do is we work proactively to make those exchanges that are win-win-wins like sending the NP to a patient's home that may cost us $200 to deliver, you know, prescriptions care rather than ignoring that patient for two weeks and having them show up in the emergency room for a $20,000 admission. So that's all we're doing. We're always making bets on things that are win-win-wins for the provider, for the patient, and for us and the taxpayer as well. That's how we're always looking at is how many more of these exchanges can we make? Can we make sure patients are on the proper meds? Can we make sure, frankly, patients that are not getting care to make sure they get care? And a lot of our patients actually, one of the things we're proud of, our patients get 85% more PCP services than the national Medicare average. And that's how we, you know, we do what we do and generate savings. You know, it's not, you know, like all we're doing is creating the environment to facilitate a better PCP patient relationship and more touchpoint. And frankly, the cost savings come from that. Okay. Um, you recently talked about acquiring the Independent Physicians Association of New York, which is one of the largest position associations in the US through your parent organization. We want to give a similar short-term or long-term plan to acquire independent practices or associations in Vermont. You know, as of right now, so we don't have any plans, you know, so for the record that IPA we acquired in New York. We don't, they, you know, only a couple of the practices are owned to out of the hundreds that they're networked with they own. So our PCPs that we work with in line and they're still independent PCPs that own their own practices. We're not managing them. We're actually big believers and independent PCPs. The data actually shows they tend to do better from a value-based care. Fight to bet. I would have to think it's probably due to the relationship. They're probably a better relationship than maybe some of these big health, you know, systems do. And for us, that was, you know, strategic and defensive, you know, we had, you know, we were working with this group for three years prior. And, you know, they were in desperate space to shell and they were looking to sell some of the big national insurers and, you know, we didn't want it to get corporatized. So part of the acquisition was defensive to keep these PCPs independent in the Long Island market. Okay. I think here's a little bit of my last question. I know this is late in the day, so I appreciate your patients, everyone's patients. On your website, there's an R-results page where you highlight your engaged practices reported 38% reduction, hospital admissions, 9% cost savings, 41% reduction, ER utilization. But I didn't see any information on there. Maybe this is elsewhere. I didn't find it. So I put that on myself, but I'm wondering how that was calculated. How was that analysis conducted? I have to get back to you on that one side, but I'm not sure exactly what data is on the website to double check it. Yeah. You may have to get back to you on that with the details. Yeah. Okay. That's it for me. Back to the board. Thank you. I appreciate it. Thank you, Sam. Appreciate that. At this point, I guess I will open it up to public comment. Is there anybody from the public that wishes to ask a question or make a comment? Walter? Hi, Jess. Thanks. Welcome to the chair, right? Temporary. Oh, come on. As a patient in a doctor's practice, I've been getting these phone calls, like from people asking me wanting to manage my prescriptions and stuff like that. So I asked them, will you be billing Medicare for that? Of course. Is that what you guys do? One of the things, I mean? Yeah. So a lot of our services that we offer, we do not bill Medicare. So Medicare, interestingly, Walter has a rule where if it is something that they deem as a billable service, legally you have to bill Medicare, because that's how Medicare collects it. So, for example, if we do a house call, we send an NP to do a house call. Yeah, we bill Medicare for, you know, an office visit or not like a house call visit. So, you know, and that's sort of required by Medicare. It's actually considered, I don't know if it's illegal or looked down upon not billing, but we do have a lot of care coordination and, you know, care coordinators that work to help get patients connected with certain things. Those type of activities we do not bill Medicare for. Now, you're a private equity firm. Yeah. Before you move on to that one, Mr. Carpenter. So we do have pharmacists. Okay. All right. Thank you. Thank you, Walter. We do have pharmacists that work with us. So they sit in in the particular space, typically in the, for folks who come out of the hospital to make sure that they get that med rec done. That's been proven to be an advantage to keep people from returning. The other thing that we would do is medication management, which I think is what you're talking about, but we wouldn't do that randomly just to make money. It would be someone who was on multiple medications and we would check with the primary care provider and say, hey, can we have this conversation and maybe reduce your medications, not necessarily add more, but deep prescribe, if you will. These folks are just calling me out of the cold blue, you know, I had one two weeks ago managing med, you know, your meds and all that, like, hmm. And when I asked the question, you know, Medicare billing, well, yeah, we'll have to. My second question is, what do you hope to get out of Vermont? You're a private equity firm, right? So you've got a lot of investors and all that. You're here in a small state. What's your purpose in being here? Yeah, could take that. So, you know, you're not here for your health. No, you know, Walter, we really believe that if we have aligned incentives, so the way, you know, we succeed, we don't succeed unless our patients succeed, unless you have a good experience, a high quality experience and we're able to lower costs. That's the way these programs are built. So, you know, we're not able to just go in and restrict care or cut staffing to cut costs. That's not, we're not able to, even if we wanted to, we're not able to, that's not the way the program works. The program works by just, you know, by doing a lot of the proactive stuff. Like the example we said, you know, rather than ignoring Mr. Smith at home, who's not able to see her PCP. The PCP may have stopped prescribing the medications because they haven't seen Miss Smith in nine months, rather than this being a ticking time bomb waiting to go to the emergency room and have a high cost encounter. Since we're the party on the hook for the costs, we have teams looking at data and analytics and live data that we're getting in order to see, okay, how can we prevent this $20,000 hospitalization in a month? Okay, we could send an NP to do a $200 house visit. So, you know, when you look at it from a society perspective, oh, they cut, you know, they took out $19,800 from healthcare. But whether you talk to Mrs. Smith or Mrs. Smith's family, they're happy that she was treated at home with a simple solution rather than needing to be hospitalized for a week and exposed to, you know, hospital acquired infections. So that's what we're doing is how can we make decisions that help everyone, the PCPs, the patients, patients, family members, you know, and that's how we're always like looking at things is how do we make win, win, win, because we cannot win if our patients are losing. Patients are getting sicker, they're in the hospital, they're not having a positive experience or a low quality care. We actually lose money and we don't get paid. So I think the fact that we're aligned, patients, PCPs and us is what, you know, is what makes this model in my opinion very successful and different from a lot of governmental models that I think have their own problems. But, you know, and for us, whether it's Vermont or any other state, we view all the states the same, Medicare is a federal national program, so we don't really discriminate whether it's, you know, Vermont, New York, New Jersey, wherever there is a group that's interested in working with us and, you know, and they're willing to engage with us, we'd be willing to go there, even if that was Hawaii. We are, we are also growing our presence in New England. We have multiple practices working with us in New Hampshire. We're growing in Maine and Massachusetts as well. So it's more of a regional approach. Walter, not necessarily for Vermont, but for New England writ large. Great. Thank you. Thank you for finding your meaning of success and winning. For us, success and winning are, I guess, maybe I'm not, maybe I'm not so sure the difference between success and winning is, but what I think it is, is for us, as I said, you know, patients having a higher quality experience, great experience, lowering costs, and also our clinicians having a good experience. And that's how we all win. And ultimately the Medicare taxpayer also wins by having lower Medicare costs. And these programs, Walter, have actually been proven a cost ACO programs in general. They've saved Medicare, I believe, in the tens of billions of dollars since they started several years back. Because if you think about it, Walter, typically in the healthcare system and a fee for service world, you have no person responsible for the patient. They're just responsible for you when you're in there for Walt. But once you leave, in a lot of cases, you don't have that responsible party. But by having someone on the hook, now you have someone that's responsible to make sure that you or whoever maybe gets what they need in order to, you know, have the best possible healthcare outcome. Thank you. At this point, I think, Walter, given our late time, I'm going to just open it up to anybody else with public comments and try and wrap this hearing up. So anybody else that has a public comment or question to make? Okay. Well, at this point, I think, given our late hour, I want to thank the vitalized team for coming today and presenting this information. And also, Claudine, I know you've been behind the scenes doing all the hearing work. And to our staff and, you know, for all the hard work in preparing us for this hearing and asking great questions. So thank you very much for all of that. And we will be looking forward to analyzing this submission in the coming weeks. Is there any new business or old business to come before the board? Is there then a motion to adjourn? So moved. Second. All right. All those in favor. They say aye. Aye. Aye. Aye. Thank you all. Have a fantastic rest of your week and appreciate all the hard work in this submission. Thank you. Thank you very much for your time. Appreciate it.