 So welcome back everyone. My name is Kevin Mullin, Chair of the Green Mountain Care Board. I'm going to call the board back into session. And the first item on this afternoon's agenda will be the minutes of June 9th. Is there a motion? So moved. Second. It's been moved by Maureen and seconded by Jess to approve the minutes of Wednesday, June 9th without any additions, deletions or corrections. Is there any discussion? Hearing none, all those in favor of the motion please signify by saying aye. Aye. Those opposed, please signify by saying nay. Let the record show that the minutes were approved unanimously. The next item on this afternoon's business is going to be Vermont Information Technology Leaders and I'm going to turn the meeting over to Sarah Kinsler, Sarah. Thank you so much. I'm just gonna take a moment to share my screen. Are folks able to see the first slide? We can, yes. Excellent, thank you. So for the record, this is Sarah Kinsler, Director of Health Systems Policy at the Green Mountain Care Board. I'm going to give you a very brief overview of the board's oversight authority related to the Vermont Information Technology Leaders budget. Vital is Vermont's designated sole health information exchange network. I'm also going to summarize Vital's budget submission presented on June 9th and give a staff recommendation. And I believe that there is a potential vote noticed for today. So as part of its oversight and policy making activities related to health information technology and health information exchange, the board is required to review and approve Vital's budget annually. This came to the board as an authority in 2015, first exercised in 2016. The board's oversight is intended to provide strategic guidance and policy parameters. So this side summarizes Vital's FY22 budget submission and I will not read it thoroughly for you, but I'll just say for revenue, Vital's got 1.6, 1.7 million. State funding is the vast majority of that. And that is an increase from Vital's previous budget forecast. And I'm using the budget, the FY21 mid-year forecast as a comparison point because there was kind of some up and down in there in the previous fiscal year. This reflects a significant shift in scope between the calendar year 2021 and 2022 contracts between Vital and the Department of Vermont Health Access, its primary funder. In addition, there's a slight increase in non-state funding on the other side. For expenses, Vital's got 11.2 million. Biggest categories here are labor-related expenses, including salary and fringe, consulting and contract labor. Vital in their budget presentation gave an overview of kind of why the consulting and contract labor line is so high and why they're kind of preferring to lean on that for some shorter-term projects, as well as software and server and maintenance. Vital's also included some built-in contingencies on both the revenue and expense side to kind of protect against lost revenue for expenses greater than predicted. So moving on to the review criteria, the board's annual Vital Budget Guidance, which was first approved in April, includes four principles for use in reviewing the budget. And these are very similar to the principles we've used in the past, but are now kind of codified in that guidance. These are listed in the guidance as well as on the board's website. And in the following slides, I'm gonna walk through these criteria along with the staff assessment of whether the criteria were met. So first, the review process will be transparent. Transparency is measured by compliance with the budget guidance and the overall transparency of the budget process. And in this case, staff finds that Vital has complied with the budget process. The budget was submitted in a timely fashion and it includes all the requested components. Vital also responded to board members' written questions about the budget in a timely fashion and provided additional information where requested. The narrative that Vital submitted, the FY22 budget documents, as well as Vital's most recent audited financials and Form 990 are also posted to the GMC website and there's a link included in the slides here. Secondly, the review process will incorporate public input. And here, Vital presented at the June 9th board meeting and responded to comments and questions from board members as well as the public. And in addition, there was an open public comment period, a special public comment period, that was open between June 9th and June 18th and we received no written comments. Third, the board will review Vital's budget order in order to determine whether it reflects strategy and priorities consistent with the state's health reform goals and the HIT plan. More commonly known as the HIE strategic plan these days. The board won't direct the technical details of Vital's work or the details of Vital's contractual relationship with the state, but we're really focused on those HIT plan goals. So here, staff assessed alignment relative to the goals of the 2020 update to the HIE strategic plan. That's the most recent version. It was approved by the board in November and is available on our website. And we found that Vital's budgeted activities will advance the goals of the HIE plan, which are listed on the prior slide by pushing toward more effective foundational services, exchange services and end user services. These are categories which reflect the Office of the National Coordinator for HIT's framework for describing critical health information exchange services, which our HIE plan relies on quite a bit and which is pictured here. The budget submission includes a table, which I've referenced here on the slide, table one, section one. It's on page five of the narrative, which really categorizes Vital's revenue and revenue sources and major projects by these categories, which we found helpful in making this review. Finally, the board's review process must be structured and timed in order to assist Diva and Vital in negotiating timely effective agreements each year and staff have worked closely with Diva and Vital to prepare the timeline for this year's budget review to make sure that that was the case and we'll ensure that that written decision stemming from any votes will also be sufficiently clear. So given those findings, staff recommend approving the Vital budget as presented with two conditions. First, Vital will comply with quarterly reporting requirements described in the annual budget guidance. And in addition to topics and metrics described in that guidance, we identified a couple of specific areas here that we would like Vital's quarterly reporting to include updates on. First, work on designing the future financial model, including charging fees to users of services. Second, Vital strategic planning process, which we heard a little bit about at the June 9th meeting. Third, work to pilot integration of claims and clinical data in the VHI. And fourth, continued work on consent in particular for sensitive data types. And then the second condition is that Vital, that staff recommend is that Vital will comply with the mid-year budget update requirements as described in the annual budget guidance. That is all from the staff recommendation. Does the board have any questions about Vital's budget or the recommendation? Thank you, Sarah. Does any member of the board have any questions for Sarah? I do. Just a quick one. I was interested in their sustainability modeling and how that related to their unrestricted net assets. I asked a question about that during the process. And I'm just wondering if, Sarah, you would feel it reasonable on your draft motion here to say, Vital's strategic planning process, including the sustainability model, profiling desired level, the desired level of unrestricted net assets, because it was a big number. It was like 45% of their income. And I just want to make sure that doesn't get kind of lost in the conversation as we move forward. I don't have a problem with it. I just want to highlight it. I am very comfortable with amending that proposed motion. I think that that makes great sense. So for the purposes of discussion, Tom, how about you make a motion? Okay. I make a motion that the staff recommendation, the amended to include language following Vital's strategic planning process, including the sustainability model profiling the desired level of unrestricted net assets. So Tom, can I interpret your motion to be that you're moving as we see on the slide plus the additional language regarding the strategic planning process? Absolutely. Thank you for clarifying my intention. Thank you, Tom. Is there a second? Second. Okay. It's been moved and seconded. Before I open it up to the public for public comment, is there any further board discussion? Hearing none, I'm going to open it up for the public for any public comment. So I'm not seeing any hands raised and I'm not hearing any public comment. So again, I will throw it back to the board for any additional comments. And hearing none. All those in favor of the motion, please signify by saying aye. Those opposed, please signify by saying nay. With the record shows unanimous decision. Thank you, Sarah. Thank you very much. Okay, next we're going to turn to the fiscal year 22 Accountable Care Organization guidance and I'm going to turn the meeting over to Marissa Melamed and Sarah Tuxbury. Marissa, Sarah. Hi, good afternoon, Mr. Chair and board members. This is Marissa Melamed, Healthcare Policy Associate Director and Administrator of the ACO Budget and Certification process. I'm going to go ahead and share my screen. I do have with me the full ACO oversight team. I'm going to run through the slides, but if there are any specific questions that can be answered by others, I will call on them. And I always just like to check that you can see the slides. We can, yes. Great. All right, so here's the agenda for today. I'm going to continue the discussion from June 9th where we reviewed the guidance. There was some board member discussion. We have some recommended changes. I will also go over any public comment received and then walk through those, walk through the changes, review the timeline, allow for additional questions and comments and a vote was noticed for today if the board is ready to do that. So the materials are all posted on the Green Mountain Care Board website. They include the certification eligibility form and attachments, the FY22 budget guidance attachments and appendices, workbooks. The workbooks are split into two. One is specific to financial, the other is all of your section. Also after our discussion on June 9th, we were able to publish the first version of the One Care Vermont ACO FY21 reporting manual. And I hope that this is helpful to board members and the public to see the different types of reports that are collected and reviewed throughout the year to show what type of data and information that we get ongoing throughout the year so that we can really keep the budget guidance streamlined to building blocks and assumptions around the submitted budget. So I will address some things that came up around the reporting manual during today's discussion and encourage people who have not seen that yet to review it. I'll make a note that that is a constantly sort of changing living document. There are about 33 named reports in there. As they come due, we do review them internally and with One Care and others to make sure that we're collecting the information the way that we want it. So we will update that reporting manual if those templates change, but we were able to get it up there and as complete a version as we could for now, there's some TBDs and underdevelopment on there, but hopefully it's helpful for people to be able to see what's in there. Again, the documents that are posted today have tracked changes just to show you the process that we went through since June 9th. Today's slides are only going to review the changes that we've made since June 9th. And then when it's complete and the board votes, we will resolve and clean up all those changes and post the final guidance document. So we did have a public comment period that ran from June 9th when we presented the first draft to June 16th. So we would have time to review and incorporate any comments. We did receive five comments related to the ACO during that period. They weren't necessarily specific to the budget guidance. As Susan mentioned this morning, we have some concurrent public comment periods that are going on as well as some media coverage that we think brought in some of these comments. We do consider them comments as part of this process because they came in under this process, but they weren't necessarily specific or all necessarily specific to the guidance. They are posted on our website for anyone to review. The themes and highlights from those comments, there was one that was specific to the guidance. It was a question about the threshold for an ACO's probable violation of law reporting requirements. We did review that comment to make sure that we were covering that concern and determined that it is covered through our certification eligibility process as is. The, let's say, let's take a word about that. The role for the Green Mountain Care Board's role for certification there is confirming that OneCare has such a plan. And so we monitor that through a collection and review of the compliance plan quarterly reporting and complaint and grievance reporting. So we appreciate that comment just to give us, you know, we took the time to take a little extra review there. Other comments were regarding OneCare's role in the all-payer model or questions about OneCare's value to the public. And we did, we do review those comments and consider them as part of the ongoing special comment period around renegotiation of the model. And those are shared as well with internal signatories. So I don't need to walk through each one of these slides. These are just bringing back what we went through last week. This is the contents of the certification eligibility verification. There were no, there was no changes or discussions of the certification eligibility form for FY22. So there are no changes there and staff consider this ready to be finalized. This is the table of contents for the ACO budget guidance. There were no changes since June 9th to the introduction and updated language around COVID-19. Section one, ACO information and background executive summary. There are no changes since the June 9th discussion in this section either. Section two, this is an overview of what's in this section. There are some changes that I'll review with you based on the board discussion from June 9th. So we have a recommended change to question 1B and question 3E and F. In question 1B, there was discussion and a suggestion from member Holmes to have the ACO quantify the number and type of providers that have dropped out of the network from 2020 to 2022. That would be the prior year, the current year and the budget years and to the best of their knowledge reasons for exiting. This is information that one care quantifies when they give us their network development strategy. So I think the ACO would be really putting that all together into the budget submission so that we can see how that's looked over the past couple of years. So that seems like a change that would be worth incorporating. In the section as well, questions 3E and F. So 3E, the suggestion here was that the strategies for reducing the administrative burden of reporting requirements was within 3B originally under primary care. Member Holmes suggested that this should be a sub-question for all provider types, not just primary care. That suggestion was well taken so it's its own sub-question now. And then an additional question that we added based on that discussion was description results of outreach efforts to providers to evaluate the satisfaction that providers have with ACO's program. So we added that evaluative question as well. In the payer program section, there were no changes since the June 9th presentation. In the section for total cost of care, we presented these two updated templates and we have a slight change to the second one. So the first one, appendix 4.1, total cost of care performance by payer, total ACO wide and the narrative question and there are no changes. To the second appendix, 4.2, settlement by payer and by HSA, there were some modifications to the narrative question there. And they include in sub-question A, how is the ACO using total cost of care and quality data at the local agency level to identify high value and low value care. And then there was some discussion around C there. What evidence do you have that the ACO local accountability strategy is working? The discussion was around really availability of data and if the ACO is able to or how they're able to evaluate that at this time. And after reviewing the discussion during the meeting, we actually recommended moving this to a new section, a new question within section seven, which is the population health and quality section to create sort of an overall evaluation question. So I will review that when we get to seven. Appendix 4.3, projected and budgeted trend rates by payer programs. There were no suggested changes since June 9th. As well, we discussed removal of these two appendices because they are either incorporated into new templates or the way the data is collected is no longer relevant. There was no changes suggested. Since you last spoke about that. Section five on risk management, again, no changes. Recommended. Section six is the ACO budget financial section. Again, this is just an overview of the data that's collected and the budget narrative. The financial templates are in their own workbook. They've been formatted and are ready and posted on our website. There was a couple of changes that needed to be made after last meeting. Those are available for review. I will note the financial template 6.6, hospital ACO participation. That is a template that we had marked under review. However, I did include it as it was concluded last year. It was populated and I believe we can populate that as is but have it on our list as one that we are still working on. So again, there's no changes since we last spoke about section six. Section seven, the quality population health, model care and community integration initiative. This is where we added number eight there, ACO self-evaluation since our last discussion. So again, no changes since June 9th to the data that's collected within the workbook and no changes to these suggested. These are the suggested changes that we discussed June 9th. No changes since then. So we added the distance concerns and discussion for board members. We added new question seven on ACO self-evaluation and it is as follows. How is the ACO evaluating its accountability strategy and risk model at the local HSM provider level? Level, excuse me. In your response discuss what evidence you have that the local accountability strategy as described in section four is working and if data is not available, how does the ACO plan to evaluate it? And including the evidence that you will examine and the timeline for evaluation. We also ask about how the risk management arrangements described in section five of the guidance and overall ACO accountability strategy. How do they support the overall accountability strategy to increase high value care and eliminate low value care? Please discuss both. And again, this is an effort to get the ACO to discuss evaluation of these sort of big concepts that we've been discussing through when we had Michael Baylett here and as well what you heard from Eric Schell this morning. And how is the ACO using its prior performance to improve program development? So this is our recommended question to address some of the discussion that was raised on June 9th. Section eight, other all-pay ratio model questions. There are no changes since the June 9th discussion. And again, these are just other parts of the budget, ACO budget targets. There's no questions here, no changes. These are the same slides you saw two weeks ago. Revised budget guidance here is the same. And then the monitoring plan. Again, as I mentioned in the beginning, the reporting manual has been posted to our website or review and it's a work in progress as reports come due. That concludes the review of the guidance changes. Just a reminder of the timeline. There's potential board vote if you're ready to do so. We issue the guidance by July 1. Once it's voted on, it really is just a matter of we have to clean it up and prepare it for posting. So it can be done before July 1 if it's ready to go. And the following dates we've reviewed several times as before. I don't think I need to go through all of those. And that brings me to board questions and comments. Thank you very much, Marissa. Gonna open it up to the board for any questions or comments. Robin. Yeah, I have a question actually for Mike Barber relating to the template that's under review. So if we approve it in its current form, I would assume that if there are changes made, it would need to come back to the full board to be for the changes to be voted on. Is that, I just want to confirm that with Mike. Yeah, this is Mike. I would agree unless that is delegated to staff or something else. Great. Marissa, could you just remind me what changed it, what the review you're doing on that template entails so that we can have some understanding to determine if it's appropriate to delegate? Yeah, it's, let me just, I'm gonna pull it. I'm gonna not share it because that didn't go so well last time it crashed my computer, but I'm just gonna look at it since I can speak to it. So this template is hospital participation. It's a summary of all hospitals and then each individual hospital has a tab where they divide out by payer. The home hospital spends fixed perspective payments, their dues, and then the types of payments that they're, like the types of payments that they're getting under each program. And my understanding is that the review of part there, this is something that we started reviewing and then just to be frank ran out of time, we're reviewing the sort of accounts or the different types of payments and what those remittances look like to the hospital and such to make sure that they, that we're in alignment there. So I mean, I do think it could be delegated to staff that's your choice or we're happy to bring it back. Again, this is kind of a collaborative process between us and hospital budgets to understand it's the way we're collecting and sort of matches the way the ACO gives it to us and the way the hospitals have it on their books. And it's been filled out in the past the way it is, but my understanding is that it needed to be reviewed. Thank you. So would I, just on that topic, so based on what you just said, Marissa, I would be comfortable delegating that to staff or to Kevin for approval so that if people would feel more comfortable and then if Kevin felt like it was a big enough change to bring it back, then he could obviously elect to do so, but it seems like it's pretty, to me it sounded like it's pretty much lining it up so that we're getting the right information in the right form, which I'm totally comfortable with not getting a second crack at the Apple there. Okay, other board members? No, I guess I would just say thank you to Marissa and the team there for incorporating the comments that I made at the last meeting. I like the changes and I'm very comfortable with this document. Okay, anything else from the board? Hearing none, I'm gonna open it up for public comment on the 22 guidance for accountable care organizations. Hearing none, Robin, are you prepared to make a motion? I am. So I move that the board approves the fiscal year 22 certification eligibility verification form as presented on June 9th and the fiscal year 22 ACO budget guidance with the staff recommended changes presented today and that we delegate a final review of the template that is under review to the chair. A second. Okay, it's been moved and seconded. Is there further discussion? Hearing none, all those in favor of the motion signified by saying aye. Aye. Those opposed, signified by saying nay. Let the record show that the motion carried unanimously. Thank you, Marissa. I know that this has been a ton of work and you've done exceptional work as always. So thank you. Thank you very much for that finalized and posted as soon as possible. Super. So the next item on the agenda is going to be a discussion of a request for a waiver from rule five. And I just want to reiterate again, as I said this morning, that there is a public comment period open on our website for any member of the public who wishes to review the agenda. And I just want to make sure that there are no issues to offer any comments before we vote, which could occur at next week's board meeting. So with that, I'm going to actually turn it over to Russ McCracken from our legal team to tee up this discussion. Russ. Great, thank you, Chair Mellon. I'll keep this a quick introduction. Marissa, if you could stop sharing your screen, it started anyhow. Clover Health reached out to us. They're participating as a direct contracting entity in the new CMS direct contracting model, which kicked off its first performance year this year. Clover Health is coming to the board, requesting a waiver of the board rule 5.4 regarding annual budget review and approval and rule 5.5 regarding monitoring and enforcement. Chair Mellon, as you noted, there'll be opportunity for public comment today. And then we also have a comment period open through the 29th, with a potential vote noticed for next meeting on the 30th. And with that, I'd like to turn it over to Kevin Murphy, who's the direct contracting executive officer from Clover Health joining us today. And David Ault, counsel at Fager Drinker, also joining us. Great, thank you, Russ. And Chair Mellon, this is Dave Ault. Can you hear me? And at the same time, I am sharing our presentation with you. So are you able to both hear me and see the presentation? We can hear you, we can see you and we can see the presentation. So you're successful on all three counts. Wow, I think I should quit while I'm ahead then. So brief introduction, I'm Dave Ault. I'm outside counsel with Fager Drinker and I've just been helping Clover Health with some of their direct contracting matters, including this one. And as Russ said, we have Kevin Murphy, who's the chief executive for their direct contracting entity with us here today. So I think we'll start by allowing Kevin to just provide you all with a little bit of background on Clover and on its direct contracting entity, on its sort of mission and its goals, in particular as they relate to its presence in Vermont through this model. And then I'm happy to talk a little bit about, more specifically about the waivers and the waiver request. So with that, I'll hand it over to Kevin, but please feel free to jump in at any point with questions and we'll certainly take any questions and comments at the end as well. Thanks, Dave. And thank you everyone for taking the time to allow us to present. So Dave, if you'll go to the next slide, I'll just give a quick overview of what we're gonna review today. So as Dave mentioned, my name's Kevin Murphy. I'm the executive director of our direct contracting entity. This program, along with CMS's other direct contracting entities went live April 1st of this year. We are participating in a number of states, including Vermont. And so I will give you a quick overview of Clover Health. As Dave mentioned, I'll give you an overview of our direct contracting entity and what our goals are along with how we believe that they fit within CMS's goals, as well as Vermont's model of care. And then we'll talk a little bit about our technology and how we believe that technology allows us to scale our model in other markets as well as Vermont. And then how we feel we align with the Vermont blueprint. And then as Dave mentioned, he'll kind of walk through the waiver requests that we're asking for. So Dave, we'll start with the next slide. If you could just kind of, this is a short video that will give you a quick overview of Clover Health. The audio's not playing, Dave. You're not hearing the audio? No. That's interesting. Okay, it was playing for us yesterday when we tested this with Abigail. Let me try one more time here. And otherwise, Kevin, I'll just let leave you to give a little bit more of this background. So let me try one more time here. Any luck hearing it now? No, that's right, I'll walk through. So Clover Health, our overall mission is to improve every life. And our strategy to do that is centered around deploying technology, such as the Clover Assistant, which I'll walk through later in the presentation, to physicians to improve and reduce variability in their clinical decision-making. So this is a tool that we deliver to providers at the point of care. Our thesis is that Clover Assistant-powered physicians drive incremental value and economic value, supporting our ability to offer consumers wider choice in healthcare coverage within our MA plan, but then also in programs like direct contracting, allowing us to drive lower costs and expense and improve outcomes for patients. We believe our platform reduces costs and improve outcomes across the variety of different programs, whether that's Medicare Advantage or in a fee-for-service program, like direct contracting. So in summary, our approach is to deliver Clover Assistant to providers to use at the point of care, scale Clover Assistant within the marketplace, drive more value through Clover Assistant, and then give a meaningful amount of that value back to patients, providers, and the government. And then obviously keep repeating those steps. So Dave, if you, that's a kind of a general overview of Clover and our ethos. If we go to direct contracting, yeah, that's great Dave. So those of you who may not be familiar with direct contracting, it really functions very much like an ACO with a higher degree of risk. So direct contracting is part of CMS's strategy to use the redesign of primary care to drive broader delivery system reform, improve health, and reduce costs. We support and reinforce the primary care physician to drive better care. We do this through the benefit enhancements, our Clover Assistant technology, and then we hope to lower cost and improve beneficiary protection within the program. CMS offers a number of benefit enhancements in payment rule waivers with this program, including those listed on the screen, the three-day SNF rule waiver, telehealth expansion, post-discharge home visits, care management home visits, and then also the provision of home health services to beneficiaries who don't necessarily meet the homebound criteria. We feel that this aligns very well with Vermont's efforts to incentivize health care value and quality designed to control the rate of growth and healthcare costs and maintain healthcare quality in Vermont. Next slide Dave. And so today, as I mentioned, we are operating in eight states as a direct contracting entity. Arizona, Kansas, Texas, Georgia, Pennsylvania, New York, New Jersey, and obviously Vermont, which is what brings us here today. In Vermont specifically, we have 20 providers that are participating with our direct contracting entity. They have roughly 1,883 aligned beneficiaries today in 2021 in our program. We're working to expand that effort. Our direct contracting agreement runs through 2026. So each year we hope to expand that. We will submit in September to CMS our list for 2022 of new participant providers that will be part of our network and hope to include practices in Vermont on that 2022 submission. Next slide, Dave. Before you go to the next slide is are those 20 providers strictly limited to the evergreen practice? Yeah, they are. Great question, Kevin. Yeah, they're all aligned with the evergreen practice. And I believe there's a couple of other practices that they acquired, but they're all operating under that evergreen TIN. And will you be giving us what your future plans are for expanding that footprint? Yeah, so I mean, we're currently, although the way the process works is we have to go out and contract with both participant and preferred providers in the marketplace. And we're in discussions with independent practices as well as other ACOs that include providers in Vermont. But our final submission and approval for that will not happen until September 10th. So I really, we do have plans to expand there, but I won't be able to give you formal numbers for that expansion until CMS approves them in September. And then next slide, thanks, Dave. So as I mentioned, under this program, there is a provision for both participant and preferred providers. Participant providers are primarily primary care physicians who can align beneficiaries to the program. And then preferred providers are specialists, facilities, ancillary service providers that can help support the complex or the care model in the program in a given market or for the direct contracting entity as a whole. We work with that network of providers to collaborate and coordinate care and drive all of that through our information sharing with Clover Assistant with a goal of assisting our providers really in all markets to improve care coordination, collaborate more and then as a result, improve outcomes for those patients that are aligned to the direct contracting entity. Next slide, Dave. Yeah, you can skip down. So I'll give you a quick walk through Clover Assistant. As I mentioned, that is kind of the backbone of our model and how we coordinate care amongst both our participant preferred providers within a marketplace and within our DCE. So first of all, Clover Assistant is not really a population health tool. Clover Assistant is a tool that is going to aggregate data from a variety of different resources and it's going to submit to the provider, whether they're a participant or preferred provider, customize information for that member at the point of care. So it's very specific to that patient on that date, at that visit. It's not an electronic health record. It's built to support a provider's care at the point of care, but it's not a practice management system. It's user-friendly, it's very intuitive and it only requires a few minutes of use for each visit. We do not pay for outcomes. We have a financial model for our participating practices that compensates them the same for their performance, whether they agree with the information we surface to them or disagree with that information. Next slide, Dave. And so just to give you kind of an overview of what Clover Assistant does, so we aggregate data from a variety of different resources. First of all, we get three years of claims history from CMS on every beneficiary, aligned to our direct contracting entity. We also align in each market with the health information exchange to get data on ADP feeds, admit discharge and transfer. We get overnight feeds from Quest and LabCorp on labs. We get pharmacy data and we also extract data, CCDA data directly from our participating practices, EMI. We collect all of that data, aggregate that data, then synthesize it to identify actionable insights that we believe will benefit the provider at the point of care. And I really kind of put those actionable insights into four different buckets. One is helping the provider manage complex care patients, so identifying high-risk patients with multiple comorbidities and additional services that they may benefit from, whether they're benefit enhancements that CMS is providing or additional supports and services that Clover Health Partners is providing to that provider. Secondly, there is also the ability to allow the providers and encourage the providers to accurately diagnose the complications of the member at the point of care. Then there is also clinical recommendations which can fall into a number of different categories, but alerting the provider that perhaps a patient is not filling the subscriptions that are being prescribed for them or that there is a lapse in their fills between prescriptions and then recommending perhaps that they prescribe a 90-day or 100-day script or encouraging specific medications, high-intensity statins where appropriate. And then lastly, there's a referral management mechanism within Clover Assistant that not only makes recommendation to high-quality providers within the network, but will also look at the existing providers that a participant provider of ours is using and really recommend which of those providers have the best cost and quality outcomes. So those are really the actionable insights that we surface to a provider at the point of care. So just in aligning with the Vermont Blueprint, one of the things that is very important to Clover and very important to our direct contracting entity and really my background is in house call medicine. I used to run the largest house call practice in the country and we really see in-home care is our differentiator in our direct contracting entity in all markets as well as Vermont. And we really use in-home care to improve access to care for a patient population that typically is suffering from multiple comorbidities, have a very high frailty index or are frequently admitting to the ER in the hospital. So we've used this program within our Medicare Advantage program and we've been very successful in reducing hospitalizations, providing for more days at home for these patients, improving our quality measures, and then of course improving outcomes and reducing costs. So providing in-home care, and in-home care doesn't necessarily just mean doctors and nurse practitioners going into the home. It also means social workers working to identify social determinants of health and other things that we can do to serve this patient population. And we're planning now and are in the process of scaling our in-home capabilities in all of our DCE markets. Next slide, Dave. And so we're obviously through our programs, both Clover Assistant, our complex care programs, we're looking to drive better care at lower costs and align not only with CMS's goals, but obviously with the Vermont goals as well. We do this through creating what we call a medical neighborhood within Clover Assistant, they're providing that referral support to our providers of those providers in the community that we feel provide the best quality and cost outcomes. We do have the ability through this program to negotiate discounted cost of care with preferred providers. And we obviously use Clover Assistant to support that. And then we look to drive our complex care programs to deliver in-home primary and collaborative care, home health, we do partner with home health agencies and hospice and palliative care agencies in all of our communities as well. And through that, develop a very strong transitional care program as well. Next slide, yeah. So, and obviously we feel that this aligns with much of the theme of Vermont's blueprint, where we're hoping to connect Vermonters with whole person care and really make that care accessible, where the patient is and then meet them where they feel that they can best receive that care. We do that through the development of patient centered team-based care model with our in-home care. All of our practices, including evergreen, have not only agreed to use Clover Assistant at the point of care, but they've also agreed to allow us to co-manage their high risk patient population. So, we bring in those in-home care programs. We create a team-based care model and we collaborate with evergreen and other practices that might come in the future on supporting that care for those services. And then we develop a number of high-intensity support services for patients in their home to help support those needs. And then next slide, Dave. And then again, a lot of this is driven through Clover Assistant. So, we support and will support all of our practices, including evergreen and other future Vermont practices with technology and resources. We connect them, both the patients and the providers with community resources. And I think it's important, obviously these patients remain Medicare fee-for-service patients, so both the provider and the patients have the choice to select any provider that is a Medicare approved provider. We're just making recommendations to both the provider and the patient. We work to improve their access to care and support any additional services that they may need. And we do this all, obviously, to improve outcomes and reduce healthcare costs. And we do deliver analytics. We do all of the back office, population health to identify high-risk members. We surface them through Clover Assistant to our practices to get their approval and their clinical recommendations on whether or not they agree that this patient could use additional benefits provided by CMS or services, provided by Clover Health Partners. And we share that information with a provider, hopefully to help them improve outcomes. So I think, I know I kind of went through that rather quickly, I think perhaps Dave, I don't know if it's best that maybe we, before we jump to the waiver request that maybe we open up for questions or do you want to go to the waiver request first? No, I think that's great. Okay, so the way it works in Vermont, just so you both know, in addition to any board questions or comments, at some point we open it up to the public for any questions or comments. So it might make more sense, Dave, if you just kept going and then we could do everything all at once. Sure, that's fine with me. That sounds just great. And as I'm, thank you, Kevin, as I'm hearing Kevin talk about the blueprint in Vermont's plan for healthcare, of course the blueprint falls within CMS's healthcare payment learning and action network, the LAN framework for moving away from fee for service reimbursement. And so this is just the same way that the OneCare Vermont does with the Vermont All-Payer ACO. That's exactly what the Clover DC and other DCs are doing in this model is just advancing additional payment and delivery system reform initiatives to move away from fee for service. So to that end, I think it's just another opportunity for providers in Vermont and beneficiaries in Vermont who aren't already in value-based care, who aren't already in a fee for service program that's really driving value to become involved. And so as you look at sort of addressing chronic care in particular for Vermonters, which I believe is always a huge portion of medical expenditures, I think that Clover's goals and Clover's aims will fit very well with that. But turning specifically to the waiver request. So as Russ said at the beginning of this portion of the meeting, we are seeking a waiver for two of the GMCB rules, rules 5.400 and 5.500. And we are requesting that under rule 5.601, which allows you as the board to waive any provision of rule five for unnecessary hardship delay for other good cause. And so in particular, as it relates to Clover, we think the two that are really relevant to the situation here with the direct contracting model are the unnecessary hardship and just for other good cause. The unnecessary hardship because, and I'll get more into this of course, but unnecessary hardship because this is already information that is being provided by Clover to CMS, this being monitored by CMS as Medicare remains the payer here, right? So Medicare is the payer. These providers are still operating and Clover is still operating within fee-for-service Medicare and have to meet all of the Medicare program requirements. So that's the hardship piece. And then for other good cause, again, it's not just the burden piece, but the burden of reporting separately, but also the fact that this is already done. So it would just be a duplicative effort. Looking at the, let me go right into actually rule 5.400. So this is the rule for budgets and payer programs. And the requirements of rule 5.400 are really centered around budget and the related ability of an entity to successfully perform its duties in coordinating care and providing care. But if you look at these tools, they really appear mostly focused on the governmental runs like a Vermont all-payer model or maybe other all-payer models. Not something that's a model or an organization such as Clover's DC, which is specific to the Medicare space. It's exclusively a Medicare ACO or a Medicare Direct Contracting entity. And why that's important is because if, 5.400 is really a way of documenting and demonstrating compliance with rule 5.200. So if you look at sort of the certificate, which are the certification requirements. So if you look at the ACO certification requirements, these kind of go hand in hand with those requirements. But of course, since 5.200 doesn't apply as a Medicare only ACO, many of the requirements under 5.400 just are not relevant. And I'll get specifically to them, but the meat of 5.400 is 5.403, which is the part that was, I think it's 22 requirements for annual reporting by an ACO. And again, those requirements are about the business model, the prior experience, and the ability of the DCE or ACO to provide care, to provide high quality care to Vermonters. And so if you look at what CMS requires, there's actually a couple of different protections that are in place that hit on all of these requirements. So first, before Clover was even accepted or allowed to participate in the program through his application, it had to demonstrate very specifically, how it performed under prior or current outcomes models or outcomes contracts. It had to demonstrate and show its business model for participating in the direct contracting model. I had to show how it was going to fund DCE activities. So how it's going to fund the benefit enhancements or the benefits that it's providing to beneficiaries, how it can demonstrate the way it's going to interact and contract and pay with the providers that are part of the direct contracting entity. And on the care coordination piece, so beyond the budget, it had to demonstrate using that budget, the promotion of evidence-based medicine, how it was going to coordinate care and care transitions, tie in social resources, provide individualized care. So all of these components were part of the application upfront. CMS reviews those, collects additional information as necessary from potential DCEs and only allows DCEs to participate that have demonstrated that it can meet all of those components. And then, so of course Clover met those and was accepted into the model and into participation. And then the second part comes with the participation agreement, which is the contract that, the actual formal contract between CMS and Clover for its participation. And you may be familiar with these participation agreements from the Vermont all payer model, they are somewhat similar. So if you're familiar with that contract, you're familiar with this contract in large part as well. But that requires ongoing obligation to continually report on any changes to governance or organization or care strategy, care model. And significantly, there also is a expanded requirement for a public website that does public reporting that's available to everybody. Clovers is cloverhealthpartners.com. So if you want to go and visit it, but this is a really valuable tool, not just for providers, but also for beneficiaries because it has to be updated to always have, you know, not like the name and location, the governing body, the clinical leaders. And it also includes the lists of all the providers. So anybody can see what that network as if you will is in terms of the participant providers and the preferred providers. This public reporting page is also where Clover is required to annually update based on his performance in the model. So you can see it'll be noted how it's performing financially. So how, you know, is it meeting its financial benchmarks, savings and losses, and also quality performance. So in order to stay in the model, you have to meet quality measures, performance on quality measures. And so those are also reported annually on the public reporting website. So turning back now, I said I would just to the 5.403, I'm not gonna go through each of the 22 for the sake of time. Happy to answer questions on any of the specific ones that you may have. But what I have hit on so far are the requirements of Clover that are already being accomplished or taken care of because of its participation in the model. You know, what it is offering to CMS, what it's reporting publicly. The only items that are on that list of 22 that are not already being done through its participation are some of the financial aspects of Clover itself. So if you're trying to look at differences and where those outliers are, it's things like what are Clover's expenditures? What are its costs of operation? What are its revenues? And you know, these are the kinds of things that as I mentioned before are really important for an ACO that has a fiduciary duty to the public, right? So if it's a Vermont model and where you have to make sure that if it's publicly funded in any way or if it's using the public's money that it's being done so in a fiscally responsible way. But in the context of a company like Clover, its internal operations in terms of its internal costs and expenditures are not relevant to whether it's going to be able to provide care that fits Vermont's plan within the blueprint and also fits, of course, its care management plan as submitted and approved to CMS. So if I turn now to rule 5.5, this is the monitoring and enforcement rule. And on the monitoring enforcement rule, it actually looks like this rule may have been drafted very closely in conjunction with the contracts that CMS developed for the next generation ACO model, which I think you may be familiar with as sort of the predecessor to what became the Vermont all payer models participation with CMS. And so the requirements are duplicated and almost verbatim and actually are more broad and go further with respect to what CMS requires. So, first of all, CMS requires that Clover maintain all records and track everything. So it's tracking its expenditures, it's tracking its benefit enhancements to the extent that it's providing, it has an implementation plan every year that it submits to CMS where CMS says, oh, this is how you're going to be running your model for this year. This is how your provider is going to be interacting with patients. This is how you as a direct contract handy are going to be interacting with patients. And that's been approved by CMS on an annual basis. And now they do the compliance where they follow up continually to make sure that that is the case. So in terms of compliance, it starts with the compliance plan that is put together by the direct contracting entity. So by Clover and approved by CMS. And then from then on, so from the time the model started on April 1st, going forward, there's claims analysis, documentation requests, interviews. So CMS is constantly reaching out not just to the direct contracting entity, but to the providers that are participating with it, to beneficiaries to collect information to make sure that it is in compliance. Every direct contracting entity, so Clover has to have a written agreement with each of its providers. So with its Vermont providers, CMS looks at that agreement to make sure that that agreement itself meets model requirements, that there's no evidence in there that there's any opportunity for provider or for Clover to do something beyond what is acceptable in the model. And in fact, this audits, I think I got an email last week because audits have already started for this year for this model for the direct contracting entity. So I think those contracts, I haven't talked to Clover about this, but I think those contracts are already being reviewed now. And then there's ongoing audits. They're looking at medical records, charts, all the other data that they get data from the providers too. And they use that along with additional documentation requests to make sure that it is meeting all of its obligations. So, all to say that in addition to what's already being publicly reported behind the scenes, by agreeing to participate in this model, Clover has agreed to open itself up and accordingly, its providers that are working with it have agreed to open themselves up, their books, their people, everything to CMS. And CMS has a contractor, an audit contractor that does nothing but full-time looking at these 50 direct contracting entities, so including Clover and monitoring to make sure that they're fully in compliance with the model. So with that in mind, turning to the, so that's sort of the comparison of why a waiver we feel is appropriate and necessary because this is already being done and that to require additional reporting separate from what is being done to CMS, to require a separate process for Vermont or alone for any other state, is overly burdensome. So for one thing, the information that Clover submits to CMS is done through a data system that CMS has created called for innovation or they call it for when they're talking about it. And that is the way that all of this documentation, a lot of these records are communicated between CMS and the direct contracting entity and Clover. So to turn around and try to create a separate process for flowing data, flowing information to Vermont separately from what is already being done is a process that would cause significant burden on top of the audit burden and the administrative burden that the model already puts on them in terms of the personnel required to do with the technology required to do it and so on. And beyond that, because this is operating in the context of the Medicare program, so part A and part B of Medicare, CMS has constant access to not just the claims data, but it has a constant access to enforcement data. So in addition to Clover's responsibility to report on things like investigations, that is something that internally through its fraud office, through its public integrity office, CMS is constantly tracking on. So they would be paying for any provider or for the direct contracting entity. There are any investigations, if there are any other issues that they need to be aware of. And so with that, I think that this additional burden is just not necessary for Clover. And the final point that I'll make, and this just goes to the sort of general idea of the reason for having reporting requirements in general is for protection of the providers that are practicing in Vermont. It's for the protection of Vermont residents to make sure that those Medicare beneficiaries are needing and receiving the care they receive. So in the direct contracting model, Clover can't do anything to reduce or avoid necessary care for patients. The patients will always retain their choice to see any providers they want to see. I mean, these are really central components of the model that remain in place and will continue to remain in place. And they can't take any action to target one set of beneficiaries or to make sure that they're only going to, if you talk about, Kevin mentioned how in the coming year or over the life of the model, there may be additional providers in Vermont participating with Clover. That's fine, but Clover cannot do so. It's not allowed to do so and wouldn't do so in a way that only targets a certain subset of beneficiaries, whether it's beneficiaries that are healthier in some way or so you're not allowed to do that. And so these are sort of some of the protections and the integrity concerns that I think that the board cares about and should care about but that are already covered by the participation in the model. So with that, I'll pause. Happy to take questions, Kevin and either Kevin or I are happy to take questions from you all and from the public who have joined. Looks like Kevin just left the meeting instead of hitting himself off mute. Okay. So I'm leaving the meeting. Oh, I'm sure he'll be back. Yeah, I saw it go leave the meeting. Okay. Well, while we wait for a moment, would it be helpful for me to, for now to keep these slides up on the screen or would you prefer for this discussion portion for me to stop sharing so that you can see everybody's faces instead? I'm okay to stop sharing but someone else wanna see this. Yeah, it makes sense. You can always bring them back up if needed. Great. I can start with a total question. I'm just coming back online. My computer just went crazy. Did everybody else stay through that process? Yes, we were here tonight. We thought maybe you hit the leave button instead of the on mute. No, the computer just started making this god-awful noise and everything went dead on my end. So I apologize. I'm sure it wasn't easy to close the comments. So, Jess, did you take over in my absence? No, we knew you were coming back. We could tell it just something had a technical glitch. We just assumed you were coming back. So it was opening up to questions was sort of the next part, but we were waiting for you. Okay, great. And I had planned on taking questions this afternoon in the reverse order from this morning. So I'm gonna start with Maureen first. So Maureen. Thanks. Yeah, I was starting without you. Just a couple questions and you alluded to some of this. I mean, first, thank you for the presentation. And obviously you do provide a lot of data to CMS. But in any of the other states that you operate, do you have to do any other additional reporting requirements in those states? So great question. The answer is no. So none of the other states require certification and none of the other states require any supplemental data reporting as well. And in fact, beyond Clover, I've looked into this for the other organizations as well in reaching out to about 15 to 20 states and none of them are requiring certification or additional data. In fact, California just last week came out with its opinion or its determination that for direct contracting and he's just not gonna require certification or data reporting. Okay. And then the materials that you provide to CMS, I mean, is it segregated by state at all so that if we wanted to look at information just for Vermont, from what you do submit? It is not segregated. The data is for all providers and all beneficiaries. Obviously within a data system, the providers are identified. So is there a way that it could be segregated such that providers could be pulled out and you could try to pull claims associated with them? I mean, again, that gets to the burden part where is it possible in a data system to pull them out? It may be, Kevin may be able to speak better to that than I can, but it would certainly require significant effort and maybe sort of development of new computer data processes to do so. And have you done any projections on opportunities for growth in Vermont and how much that could be? Yeah. So I mean, we've looked at, we do have all of the practices in Vermont identified and whether or not they're affiliated with other payer models. So participating in other Medicare shared savings programs or other programs. And we are specifically talking to FQHCs and rural health clinics. We have a number of rural health clinics in Kansas and Georgia that are participating with us. So we have looked at the market and identified practices that we think would be a good fit for us. Yes. Do you look at all to either here or any of the other states expand out of this Medicare program? Not presently. I mean, this is really our focus right now. Okay. Those are all the questions I have now that everyone else asked some of the other questions. Thanks. And Maureen, I would, sorry, just to respond a little bit to your final comment too about expanding beyond Medicare. Obviously if there ever was a point that Clover decided to expand beyond just participating as a Medicare ACO, that obviously I think that would require another conversation with Vermont. So I don't think there should be any concern about that happening behind the scenes or happening. I mean, I think that this conversation and the request for these waivers are based on, based on an understanding and a representation that Clover Health is participating only as a Medicare ACO or DC is the case maybe here. Yeah, and I would think that obviously depending on what the board decides in the future on whether or not there's a waiver or not, there may be an expectation that there still would be further conversations anyway. So. Yeah, fair enough. And I wasn't trying to foreclose that either, right? Right, right, yeah. Okay. Okay, thank you. Member Pelham, Tom. Hi there. So I just want to follow up on the issue of Vermont having access to CMS files as they, I'm understanding that there isn't a segregated file that is just a Vermont file, but obviously there's correspondence and contract relationships and things of that sort between Clover and CMS. And I'm wondering would we have access to that on a targeted basis? Should there be something that we want to see? So access, just to make sure that I'm understanding your question, would you have access to the documents or the contracts between Clover and the providers that are operating in Vermont is in those sorts of documents that sort of the non-claims, non-financial documents, am I understanding you correctly? No, I guess I'm worried. I'm okay, let's do a worst case. We hear from some Vermonters who have been serviced by the Clover assistance system that things aren't going very well. And so, and that there's some history of that and that we would want to know about that. And so on a worst case, if we file a Freedom of Information Act to say, let us see the pertinent materials associated with these, with this issue, names crossed out, whatever. You know, would we be able to do that and would you have any objection to us doing that? Yes, so, and Kevin, please feel free to piggyback on me here with your own thoughts, but to two thoughts on that, one is that there is a grievance process either for providers or for beneficiaries in place through the direct contracting model. So every year, Clover has to send all of the beneficiaries a letter saying, you're aligned to, you are part of this direct contracting entity for this year. And if you have any questions, if you have any problems, complaints, you can reach out and they can contact CMS. And so CMS handles those and investigates those. Actually came from the Innovation Center running the NextGen model. And so I know that they take those very seriously and do follow up with those. So any grievances would be addressed as part of the model. So that's sort of part one of my answer. And so I don't know that that would be necessary. And then that contact information is also available, of course, on the public website as well for Clover's DCE. But the second part is, I know that Clover also wants to be a good partner with Vermont and be a positive presence to patients and to the state. And so to that end, I think that, Clover was certainly open to helping you all in any way that doesn't create a significant ongoing burden for the organization. So some tactical burden in a few instances you might be open to as part of a waiver. Yeah, I think Kevin speaks to that, but I think that sounds reasonable. I think that part of this burden comes from the annual reporting requirement of this and being a, so this isn't an open-ended forever kind of a thing anyway. So this model is a roughly five-ish, five-plus-year model. And so the likelihood of things changing significantly over those five years are not significant. And so requiring that annual process, there probably wouldn't be much information that would even change from year to year if any from doing so. So how old is the Clover assistant system? How long has it been around in active? Yeah, so it's been around in active, I would say for three years. It's been used within our Medicare Advantage plan extensively the last two years. And this year in direct contracting and Medicare Advantage. And so its implementation has been rolled out a few times, more than once. Oh yeah, yeah, I mean, yeah. So we have about roughly 60,000 Medicare Advantage lives. About 60% of the patients in our Medicare Advantage plan were seen using Clover assistant last year. So roughly 36,000 lives. So where has the rollout been the most problematic? Where has the rollout been most problematic? I mean, I think, look at that. So Clover assistant is a tool for the provider, it's not necessarily the patient. I understand that, I understand that. So Clover assistant has a net promoter score in the high 50s, low 60s. If you were to compare that with any EMR, it's not an EMR, but that would be the most relevant system to compare it to. They're typically in the single digits, sometimes negative. I wouldn't hold up the EMRs as a point of comparison. That's my point. I mean, so it's hard for me to say where is the most, providers that are using the tool, you don't like the tool because it provides them with information that they normally don't have access to. So, it's hard for me to say where has it been problematic? I mean, it's really, where it's problematic is if a provider doesn't feel that the extra two minutes that they have to spend with Clover assistant are worth their time during a visit. But that would really be where it's problematic. Does a provider want access to that information and are they willing to spend a couple of extra minutes per visit to access it? But there's been no problematic technical problems with the system. No. Systematic problem with the system. No. Thank you. Thank you, Tom. Member Launch, Robin. Thank you, and thank you both for being here today. So I did go and look at your website and it's because your performance here just started this year, of course, you don't have financial and quality performance data up, but I'm wondering when you would expect that to be posted for the 2021 performance here. Yeah, so we won't receive that data until July of 2022 from CMS. And I'm assuming that that data will be aggregated and not necessarily broken out by state? That's correct. Okay. Yeah, and so the reason the CMS allows for a three month claims run out before they wrap up a year. So yeah, so anyway, so that's why there's a bit of a delay in publishing it. Yeah, we're very familiar with that since we do our own reporting to CMS under the all pair model. So in terms of the benefit enhancements, I'm wondering if you could talk a little bit about how those are implemented in your model because I, well, in particular currently with just one practice and no preferred providers, at least according to your website in Vermont, like how do you actually implement that benefit enhancement? Or is that something that would be implemented not this year for any Vermonters given that it's one practice? Yeah, so I can give you the answer to both questions. So specific to Vermonters, I mean, we are actually working with a couple of different preferred providers we can add at any point in time during the year. So we're actually working with a couple of different preferred providers that we would expect to add this year for Vermont. And those would primarily be home health, palliative care hospice, skilled nursing, entities like that. And then how we execute, we had to submit an implementation plan to Clover, I mean, to CMS for each one of those benefit enhancements. Sure, as did we for our model. Yep, so I'll just pick one as an example. So for, like if we were to take the post discharge visit as an example, if we got an ADT feed that indicated that someone had admitted and was discharging, we would alert the provider as well as a preferred partner in the marketplace. So if we have a home health agency or a in-home care service in the market, we would notify all three of them that that individual had discharged. And if we believed that they were high risk and at risk for readmission, we would request that first evergreen, see the patient within 48 hours. If they were not able to see them within 48 hours, we would ask their permission to have either our home health partner or in the home care partner to see that patient in the home. Once they see the patient in the home, they would then assess the need to continue with a recommendation for follow-up in home care visits. And that post discharge benefit enhancement allows for up to nine visits in the home within 90 days. So let's say it was a home health agency, they would make the recommendation, this patient needs two, three or four visits. They would submit that recommendation to Clover. We would review and approve that recommendation. And then, the appropriate level of provider would serve that. We have to document all of that and be able to provide that information back to CMS. The entire process, the review, the approval and the actual visits. Great, thank you. That's very helpful. I was trying to get sort of a very practical understanding of how that works in your model. Similarly, in terms of your in-home care model, who would actually provide that care? Like a preferred provider in state? Or ever? Okay, all right. Yeah, so, wait a minute. I just wanna be very specific. So, our approach is to support our providers that are part of the network. So, if Evergreen had a very robust in-home care program and social workers, so we surface the need that we believe exists within Clover Assistant. Victoria Loner. If that practice is capable of fulfilling that need by themselves, then they of course will do that. We just wanna make sure that somebody does it. If they're not able to do that, then the intent is that we have supplemental resources that will provide that or fill that need. But are those supplemental resources existing Vermont providers? Or are they other providers that you would bring in from another state? Or would it be somebody through telehealth? That's what I'm trying to understand. So, it's a combination. So, they're obviously licensed within the state whoever is providing the care. And depending on what the exact need is, you know, it will either be an in-home resource. Typically, there's always a local resource that is part of that model. But in some instances, it could include telehealth. We're perhaps a nurse is going in or a social worker is going in, but a provider may be telehelping in with that visit. Got it. Okay, thank you. That's very helpful. I had, my next question was around in your March 11th letter from Mr. Ault, you indicated that you might be developing a shared savings program. It sounded like that would happen in performance year one, but could you speak a little bit more to that and then connect the dots with me from your slide indicating that you're paying for the use of the product and not for outcomes? How do these two put together? Yeah, so I'm a shared savings model. We have not finalized the shared savings model for 2021 we do intend to. Our challenge is we have a large variety of different practices that are participating. We have like an optimum practice that has a couple of hundred providers and 20,000 patients. And then we have solo practitioners that might only have 50 or 100 patients. So we're trying to develop a model that is fair to everyone. Our intent is that we share up to 50% of the savings with our participant providers. And in our agreements with them, we've committed to doing that, submitting and developing a plan this year that would be effective for this year. With regards to Clover Assistant, we do pay our providers, we pay the way we've structured our direct contracting entity is that they receive 100% of Medicare allowable. They're still submitting all of their claims to CMS and CMS is still adjudicating all of their claims but Clover is paying whatever CMS adjudicates. So we're still paying them 100% of Medicare allowable. In addition to paying Medicare allowable, we pay them a Clover Assistant visit fee. So we pay them a fee for using Clover Assistant at the point of care for each qualified visit, which is a qualified E&M visit. And that fee ranges depending on the structure of the organization, but for you in Vermont, it's a $45 incremental fee above and beyond what they receive for their Medicare allowable. And that's guaranteed upside to the practice already. If in the event that we did not earn savings, there is no ability to claw back those payments and those payments are made weekly to the practice. If they did 100 Clover Assistant visits last week, they would be paid $4,500 this week. And just to, so our philosophy of course is that by providing a primary care physician with more information at the point of care that we will drive better outcomes. And so there is no requirement on their part to if they wanna get paid, they have to use Clover Assistant, but there's no requirement for them. Like if we recommend that a patient needs complex care, they don't have to agree with us. They just have to complete the visit and acknowledge that we made that recommendation. Got it. Okay, thank you. That was super helpful. The reason why I was in particular interested in shared savings is that with the state's agreement with CMMI, we are not limited to one ACO in our model. We actually, any shared savings program qualifies for both our scale and our total cost of care. So we would still be responsible for total cost of care for your, to a population attributed to you. So I think we need to have a little bit of understanding about the shared savings model when it comes to fruition in order to meet our contractual obligations between the state and the feds. So I just wanted to explain that because that may not, that's not necessarily, because it's a federal agreement, it's not necessarily laid out in the rule. Yeah, that's perfect. Yeah, thank you. I, is all my questions. Thank you very much. Thank you, Robin. Next I'm gonna call on member Holmes, Jessica. Great, thank you very much. Let me just pick up on the shared savings questions that Robin just asked. I'm just wondering out of curiosity, why not a two-sided risk model? Great question. Yeah, so I, we do, to be clear, we do have some organizations that, larger organizations that are participating with us that will have upside downside in performance year two, none have it in performance year one. And I think from our perspective, you know, obviously we're open to that, but the organizations that are gonna participate in downside, you know, puts a little bit of a burden on us because financially, you know, they would have to meet the same rigor and requirements that we would have to meet in order to take on that downside risk. So, you know, at this time, we've really only entertained it with organizations that have had a prior downside risk arrangement with CMS. Okay, but is there a plan to potentially bring that into Vermont in year two, or are you thinking that Vermont doesn't have the size or the experience? Yeah, so we would require a minimum of 5,000 members for downside risk. So currently we, you know, we don't have someone of that size that is participating. If we did in 2022, if we signed an ACO that had prior experience, we would be open to it. Okay, and that actually leads into my next question. And I think the question has sort of been asked, but I'm not sure it's been directly answered. I'm wondering if you could specifically tell me how many beneficiaries you anticipate having within the next five years in Vermont. So specifically a projection number that you're currently thinking about. Yeah, I don't know. It's my legal team I'm here besides Dave. Yeah, it's a public company. I mean, you know, I'm obviously often advised not to give forward-looking numbers. You know, so, and I'm not trying to be a base of either. I mean, there are a lot of complications with a new model like this that, you know, have caused some concerns from us. You know, we lost the significant number of lives last year due to, you know, the fact that this is a new model and some of the reporting requirements weren't published appropriately by CMS. And then there are also a number of entities that are in conflicting programs and don't know it. So until we submit someone to CMS and CMS approves them, you know, we're not very confident on like saying, hey, we're gonna have 10,000 lives. If you ask me how many I would like to have, you know, we'd like to have, you know, 25,000, 50,000 lives, you know, in Vermont over the next five years. I can't say that we'll, you know, get to that number. Okay, thank you. So Clover Assistant is clearly the backbone of your model, right? I mean, this technology is what you're using. And I'm wondering if you can just talk a little bit about evidence-based that you're using in developing the algorithms there and the recommendations. What specifically is the evidence-based that you're using? And a sub-question to that would be, what are the types of clinical protocols that would not have been followed by the providers but for Clover Assistant? What would be actual, give me some examples of behavioral change that Clover Assistant generates, but also I wanna know what the evidence base is too. So. Yeah, so let me, I can give you, I mean, first of all, I should have one of my medical directors and I am not a clinician. So, but I think, you know, I'll go to your second question first because I have the most experience with it. So we have great analytical models that identify high-risk patients and, you know, we use a number of different algorithms to identify those. And we have, you know, what we believe is about an 82% accuracy rate on identifying high-risk complex care patients. However, through my experience, I know that regardless of how good an algorithm is, it's not necessarily as good as a provider that has been seeing a patient for a significant period of times, intuition or gestalt. So we surface to our providers that we believe are high-risk the surprise question. You know, would you be surprised if this patient were to pass away in the next six months? That's a question that a provider typically doesn't think of. If they answer that question, no, I would not be surprised. Then we will offer some of the benefit enhancements that CMS provides or palliative care or other resources to engage with that patient. So that's an example of something that we might surface that a provider might not typically, you know, ask of or think that question and seek out other resources to address that need. You know, the algorithms, I mean, a lot of what we, you know, what we, I mean, obviously we're looking, we really focus on, in addition to Clover Assistant, we're focusing on building complex care programs and coordinated care programs that address, you know, the five to 10% of the population that is responsible for 40 to 60% of the cost and really improving access there. So a lot of the algorithms are designed to identify the need for those patients and then serve to the provider, not only the identification of the need, but the availability of resources to serve that need. You know, and that's really where a lot of our focus is. There are, there's a million other things that my medical directors, you know, could probably go over with you, but those are the things that I focus on the most. Hi, actually, this is GLE and I'm joining in. I'm a general counsel at Clover Health. I just wanted to add a couple of things that, you know, you might be wondering about in terms of the evidence-based. So we actually also met with the FDA about our tool to address any concerns that they had. And one of the very important things about the tool is that we always give the basis for our recommendations. So insofar as we might suggest, you know, given the A1C levels, certain types of medications or various treatment protocols, we would have also on that same page a link to the recommendations from the American Academy of, you know, Diabetes or something like that, or various AMA recommendations, et cetera. So it's always supposed to be helping the doctor make their own decisions, as opposed to obviously making them for them. And so we will, but in any event, there are recommendations with respect to different types of medications, given any comorbidities, as well as there are recommendations with respect to, for example, additional testing that the doctors might want to consider doing, given if there's some lab results that may be indicative of some other kind of disease that may be coming into being. So those are some of the recommendations that are in there. Okay. And just, you know, obviously in this day and age, big data is incredibly valuable. So I'm wondering if the data that's collected in Vermont and in other states aggregated and or otherwise are any plans to sell them for commercial purposes to any other entities? No, not that I'm aware of. My last question actually involves, in the application, there was a focus on care redesign, and specifically ensuring treatment in the most optimal setting by the right provider. So I'm wondering in the Vermont context, specifically in Vermont, what data are you using and what specific quality metrics and cost metrics are you using to define what is the most optimal setting and who is the right high-quality provider in Vermont? How is that referral management program gonna work? What data are you specifically planning to use in Vermont to identify low-cost, high-quality providers, optimal settings, and right providers? Yeah, so we use data from care journey. I don't know if you're familiar with care journey at all or not. So care journey is an organization based in DC that is headed by a former CMS employee, I believe, but they have access to 100% Medicare data and they do cost and quality ratings regionally that is driven by regional data on providers by provider category. So that's one of the resources that we use. And the way that we approach it, so we look at site of care is a particular provider performing the same service in a hospital setting versus an ASC setting. So obviously if they're performing the same quality of care, they're equally rated on quality, but one is delivering that service in a hospital, the other is delivering it in an ASC, there's going to be a significant difference in cost. And so if a provider is currently, when we look at their past historical data is currently using both of those, let's just say cardiologists, to refer patients to, when we make a recommendation for a referral, we would probably list both of them, but we would list the one that is performing the service in the ASC first. So obviously, referrals is obviously tricky because the patient and the provider at the end of the day have choice. We're just trying to optimize the individual provider's decision-making by giving them more information than they presently have to allow them to make a better decision. That's really the simple approach. Okay, great. I think that's it, Kevin, from me. Thank you. So in your presentation today, you were very careful to show alignment with the blueprint for health, but you didn't really show alignment with either the all-payer model agreement or Act 113. I was curious why you chose that approach. Sure. To be completely honest, I think that's a good point. To be completely candid with you is because in the conversations with the board staff, with Mike and others, they said that you were gonna be particularly interested in alignment with the state's blueprint. And so that's why I was predominantly focused on that is I thought that's where your interest lied. Happy to answer questions about other alignment. With respect to Vermont all-payer model, I think that, again, the Vermont all-payer model is sort of one piece on the path that the blueprint lays out in terms of getting away from fee-for-service and providing high-value care. So that's what the Vermont all-payer model is. And again, it's from the all-payer perspective and how the Clover direct contracting entity aligns with it is it's another tool in the state. So for instance, if there are providers that are interested in your state and taking on more or less risk that are either new to value-based care and understand the need to get involved but don't wanna take on significant risk or the other end, they feel like they are ready to take on risk, Clover is able to provide, as Kevin described, sort of like a path that's sort of tailored. So it's just another option in terms of if there are providers in your state that are looking to get involved in value-based care, the Vermont all-payer model is a great option and provides a lot of opportunity, this is another opportunity. And so I think they work hand in hand in covering even more of your state in terms of not just providers, but in beneficiaries and getting more of your patients into similar types of coordinated care, right? Where I think a lot of the care strategies that Clover is employing in terms of identifying your high-risk, your co-warm-minute co-morbidity, identifying those patients and really making sure that they need early on to prevent further downstream care that would otherwise be unnecessary and finding the right care at the right place, those are the same goals. And so it's just another resource or another opportunity for those providers to come into this space. So I would agree with you that the goals are similar. Did you look at the financial targets that Vermont is committed to under the all-payer model agreement? I have looked at them, yes, I don't have them in front of me at the moment. So with Medicare population, we're looking at two-tenths of a percent less than the trend line of the national growth rate. And so how do we, as we're trying to meet our obligations with the federal government, know that you're working in that direction and at the same time, Act 113, make sure that as you've pointed out earlier that quality isn't diminished for Vermonters. So without having any of your information, how do we know that we're meeting the financial targets while maintaining the quality? Yeah, so two different ways. One is that ultimately, as was pointed out, I believe by Robin, it's not available yet because we're just in the first performance here, but the quality information, the financial information, so the actual performance overall will be reported. So you will see that. And in terms of on an ongoing basis, there are the four quality measures that are being reported on. So it's the three claims measures and then what's called the CAHPS measures, so these patient survey measures. And you have to maintain a high level of quality in order to remain in the model. And on the financial piece of it, because it's a total cost of care model, and being responsible for the expenditures, all of the expenditures for those beneficiaries, for those Vermont patients, that is the right, and being at full risk. So they are a global direct contracting entity at full risk. So because of that, they are going to be driven to continue to meet those levels of savings that would fit with the state standards. When you were discussing what your strategy should be and coming forward with a waiver, did you at all consider a different request that might be asking for alignment with the CMS reporting rather than waiving reporting to the state? Yes, certainly considered it. Again, I think the issue with alignment with reporting is that a lot of the reporting for CMS is done through a different mechanism. So it's either done automatically. So when it comes to sort of the monitoring and reporting the compliance piece, a lot of that is data that CMS already has access to. And so, right, or it's efforts that CMS is already taking or going to take anyway to reach out to the direct contracting entity or to the providers or to the beneficiaries. So it would be, so those efforts, if Vermont was doing them, would be an additional on top. And then for the other piece, the part that for the information that Clover has to report separately, which is probably the smaller piece, that's again being reported in large part through the system that was created for these models by CMS. So to be able to align them and sort of just say everything that we're submitting to CMS will submit to you as well, to Vermont as well. It's really not as easy as that. It's not just sort of clicking a button for it to go to CMS and a button for it to go to Vermont. It would really take significant operational person power and financial resources in order to be able to provide even the same information to Vermont. Okay. You guys have made the news a lot lately. Most recently as a meme stock, but before that there were also other stories out there in the media, the Hindenburg security fraud lawsuit, the SEC investigation. Is there anything that those 1800 Vermonters that are currently affiliated with you? Is there anything that should concern them? So I'll let Kevin speak to that. And if she is on and she wants to speak to that, she used to certainly chime in as well. Yeah, I would say no. First of all, those are reports in the news. And that as I mentioned before, CMS continually, they used the Office of the Inspector General, the Department of Justice and their own Center for Program Integrity to constantly evaluate the participation of the direct contracting entity and its providers. And they're constantly monitoring all of these things, any kinds of investigations, and do not allow organizations to participate or to continue to participate if there is any concern for the beneficiaries. And that's something that I can tell you from my time at CMS is really crucial to the function of the model team that operates this model, or any of their models, frankly. Yeah, I mean, I would like, Gia, if you're on, you can speak to it, but I would echo David's comments and just say that if CMS had any concerns with Clover Health as a direct contracting entity, they wouldn't have awarded us the program. They wouldn't have admitted us and accept us as, I mean, there's been a lot of focus also on direct contracting entities. And I don't think that they would have accepted Clover if they had any concerns whatsoever. Yeah, just to make clear, we did have to submit an application and CMS has the authority at any time to revoke that if they had any concerns. Also as a public company now, we have far more reporting obligations about the nature of the company than we did previously in any event. So we think that those, we don't think that there is reason for concern along the lines that you've suggested. Thank you. Do other board members have any follow-up questions before I turn it over for public comment? Seeing a lot of shaking heads, I don't see Maureen, but I'm assuming that you do not have anything further. So I'm gonna open it up for public comment. Is there any member of the public who wishes to comment on the discussion before us concerning Clover Health and a request for a waiver? And Walter, I'll call on you first. Thank you, Kevin. And I wanted to, Kevin brought up most of the points I wanted to raise. So I won't repeat them about the being in the news lately. So thanks to Kevin for that. My question is, how much would this cost Vermont? Because you obviously aren't doing this for your own healthcare. Who your CEO is and why don't we need something like this Clover in the first place? I don't think we really need them. And how much would the data be stumbling over each other? We already have half a million data reporting agencies. And just to have another one through the technology, how much would it cross over and repeat? And how much would that cost us in the end? So our CEO is Vivek Garapali to answer that question. To answer the data group, well, let me answer the financial question first. There is no cost to the state, to us operating in the state. There's no financial costs there. And then with regards to the data, you're right, there are a lot of data resources out there. And that really is the purpose of Clover Assistant. We're trying to aggregate all of that data and surface it to a provider at the point of care to enable them to provide better care to a patient at the point of care. Today, within their own EMR, and if you're at all familiar with EMRs, there's hundreds of them out there that don't talk to each other. So in Evergreen's case, they are on Athena, which is either on Athena or e-clinical works, but one of those two EMRs, which are better EMRs when you look at the EMRs, but they don't have access. They only provide the provider with access to their own data. What we're providing them with access to is every single claim that has been filed for their patient, regardless of who the provider is. So it just as an example, if a patient admits to the hospital, one of the challenges that patients often face is they're prescribed new medications when they go to the hospital, and then they come home and they have the existing medications that were prescribed to them before they went into the hospital. Some of those medications may contraindicate and they may be taking two medications simultaneously that they shouldn't be taking. The provider will have access to that data now because they'll have all of that information when that patient comes into the office. If a specialist or a hospitalist or someone else prescribed the medication, that doctor will now have access to it, where before they did not have access to it. With all this managed care you're talking about, as a patient who has had claim denials and then refused access before, I wonder how much you would refuse access and make a profit. You have to cut that back. Yeah, Walter, that's a great question. And one of the things that there's a lot of things that I like a lot about this direct contracting program, but one of them that I like the most is the fact that we do not adjudicate claims. CMS is solely responsible for approving and denying claims. So if you were to receive a service or elect to have a service done, Clover has no ability whatsoever to approve or deny your ability to receive that service. Only Medicare can do that. Okay, other public comment? And Walter, I was just gonna add on one more thing with respect to, so if you are a Medicare or for any Medicare beneficiary who is in Medicare Part A and Medicare Part B, so if you're in the sort of original or traditional Medicare, this doesn't actually, and it's not allowed to by law, it's not allowed by the program, it's not allowed to change the way you receive your care in terms of there can't be any limiting in terms of providers you can go to. You go to any provider you want to go to just as that beneficiary would now, that provider receives the same services and so on. The only thing the model can do, the only thing, the all payer model, all payer model, the only thing that the direct contracting model with Clover, the only things they can do is perhaps offer something additional in terms of the care you receive. So providing some other benefit and again, there's no cost, no beneficiary pays any more than they're already paying for Medicare, but just to help coordinate their care. And to your question about will you have to make money, the whole premise behind this is that if you take good care of patients, so if you get the patient the care that he or she needs when they need that care and with the provider, that's the right provider to provide that care, then they're not gonna be admitted to the hospital, they're not going to have all these other problems down the road that end up being really expensive and costly. So if a Clover or some other organization spends a little more money on chronic conditions upfront for patients, it actually saves money in expenditures at the end of the road. And the way it works in this program for Clover and for the others doing it is that at the end of the year, CMS looks and says, well, Clover, you were able to prevent a lot of expenditures because you were taking care of patients early on and coordinating their care. And because of that, you share in the savings that the Medicare trust fund has, so the Medicare money, right? You share in the savings that the Medicare program saw because of the care that Clover and its providers offered. So that's the sort of the general premise as to how an organization such as Clover makes money in a model like this or how they make it affordable to participate. Other public comment? Yes, I see Eric Schulteis from the healthcare advocate's office. Eric. Hi, I'm just curious. So, you know, setting aside the question of CMS, whether CMS can be the perfect regulator before whether we should have concerns in the state. I mean, between the volume of the SEC investigation, the DOJ investigation, the class action suit, your CEOs, expletive laden interview with Forbes, and the New Jersey legislatures call for investigation. So what has, have you as an organization changed in your practices? Because we're not talking about one thing. I mean, it really is in this case, where there's smoke, there's probably fire. Kevin, do you want to start with that or would you prefer for me to? Well, or Gia. Yeah. So, yeah, I guess feel free for Gia to chime in. My response to that Eric is, you know, is that any time for, you know, for any business, any company, whether it's a public company or a private company, especially, you know, one that goes public, you know, there is going to be news, there's going to be chatter, and that's why there can be investigations. And that's why, you know, and that's the reason why CMS follows a process in not just making sure before allowing ADC to participate, so before allowing Clover to participate, that, you know, it checks again, it checks with the Department of Justice, with the Office of the Inspector General, and so on. And then together they make a determination that it's okay for, you know, that Clover is a company or an organization that should be able to participate. And if that isn't on, it's not a once in that's done, that is an ongoing process. And so, you know, it's not just, you know, the Innovation Center or the, you know, the CMMI model team is running the model, making these decisions. It's actually a much broader effort to make sure that the organizations that participate in the direct contracting model are, you know, are in good standing to do so. Sorry, I was hitting my unmute button and was hitting the wrong button. So, yeah, I would just add on to what Dave said. I mean, number one, there was that Hindenburg report to which we wrote a very lengthy response. And so I would encourage you to read that if you haven't had the opportunity yet, which I think, you know, provides our view on things. As well as the fact of what Dave just said, as he mentioned, he had worked in CMMI, as well as I was Deputy General Counsel of HHS. So I'm very familiar with the coordination that goes on between CMS, HHS, and DOJ. And so, again, CMMI has, you know, there's certain programs where everyone is entitled to participate in. In this type of model, CMMI has complete discretion with respect to what entities it will allow to participate in the model. And it has complete discretion as well to, you know, kick someone out of the model if it has any concerns at any point. So, you know, there's no obligation for them to keep anyone in the model. They're in fact, only 53 participants right now. And so, you know, to the extent that CMMI has better access to speak and coordinate with other agencies, you know, that's what we would point you to. Thank you. Okay. Other public comment? Other public comment? So I can hear somebody very inaudibly. I don't know if somebody just has background on or if they're trying to make a statement. Yeah, I think you're good now. Okay, so I'm not hearing any other further public comment. As we spoke about at the introduction to this segment of our board meeting, this is something that could likely be voted on next week. We do have a public comment period that is open for anybody to submit written public comments to and that can be accessed through our website. And we may have some follow-up questions. As we sleep on this, the individual board members giving some thought to making that decision possibly next week. No guarantees, but possibly next week. And if we have those follow-up questions, is it okay for us to submit them to you? And should they go through David or who? Yeah, absolutely. We welcome any follow-up questions. Happy to answer anything that comes up as you think about this. Feel free to send them to me and I'll discuss them with the Clover team and we'll get back to you. Super, thank you. Russ or Mike, is there anything that I'm missing? This is Mike, not that I can think of. No, not from my perspective either. Okay, great. So thank you very much. I think we've all learned a lot this afternoon and thank you. So with that, I'm gonna move to the next item on the agenda. Is there any old business to come before the board? Is there any old business to come before the board? Hearing none, is there any new business to come before the board? Hearing none, is there a motion to adjourn? Don't move. Second. Tom has moved and Robin has seconded to adjourn today's meeting. I understand it's a beautiful day outside. I haven't seen it yet, but hopefully everybody gets some time outside and thank you very much and enjoy the rest of your day. We didn't vote. We didn't adjourn. We didn't turn to have an episode. All those in favor of the motion, signify by saying aye. Aye. Those opposed, signify by saying nay. Meeting adjourned, thank you everyone. Bye bye.