 Good afternoon everyone. We're going to call the meeting to order. The first item on the agenda is the Executive Director's Report, Susan Barrett. Thank you very much, Mr. Chair. Welcome to the Green Mountain Care Board in 2019. It's been a few weeks since we've been together because of the holidays, so happy 2019. I have a couple of scheduling announcements. First, for our scheduled meetings for the month of January, I do have a change on Wednesday, January 23rd. We will not be hearing from the Qualified Health Plans on their standard plan design, but on the next week, we will be hearing a presentation from the folks at DEVA on the Qualified Health Plans, so that that press release will be updated on our website. Next week we're going to hear, we're going to have a panel discussion on strategies to reduce costs and improve quality in health care. We have a Skype visit from folks at Gundersen Health Care in Wisconsin, is it? Somewhere in the Midwest. And then we have some of our leaders from hospitals in Vermont who will discuss strategies to improve quality and reduce costs in health care. It should be an interesting discussion. And then we're also going to hear from folks in the administration on health care workforce. And then the next week on Wednesday, January 23rd, we'll hear about the ACO Certification Eligibility Verification and new criteria, which we are hearing about today. That will be out for a couple of weeks for public comment. And there's a potential vote on that day. I do want to just also mention, in terms of our schedule, next Wednesday evening from 5 to 7 p.m. at our offices at 144 State Street, we'll be conducting the primary care advisory group meeting. And the focus of that meeting will be on the reimagined HRAP. And those providers are providing a lot of input into that project. So that is also an open public meeting, and all of the materials are on our website. And that's all I have to announce. Thank you, Susan. Just one additional announcement that I'll make is that we have not had a public meeting for a couple of weeks due to the holidays, but that didn't mean that the work stopped. And one of the things that occurred in that timeframe was the request from Governor Scott for reevaluation of Vermont's eight critical access hospitals. And our initial report has just been sent to the governor, and will be on our website later this afternoon, as soon as our staff has a chance to get back to the office and do that. So with that, the next item on the agenda are the minutes of Monday, December 17th. Is there a motion? So moved. Second. It's been moved and seconded to approve the minutes of Monday, December 17th without any additions, deletions, or corrections. Is there any discussion? Seeing none, all those in favor signify by saying aye. Aye. Any opposed? Okay. So we're going to proceed with the agenda, and the first item on the agenda is a discussion of our HIE Consent Policy, and we'll welcome the team from AHS to come forward, and Michael and Steve, welcome. Thank you for having us. Is this catching my voice? We're here to report on the progress of Diva's inquiry into whether or not the HIE should continue on with an opt-in consent policy that applies to whether or not an individual's health records are accessible on the exchange by participating providers, or whether we should consider switching to an opt-out policy. So some of the background is that in under Act 73, there was a comprehensive review conducted of the VHI, the Vermont Health Information Exchange, which was conducted by an organization called HealthTech Solutions, which has expertise in health information exchange technology law and operations in many states. One of the issues identified by HealthTech in its analysis, which was submitted to the legislature in November of last, not last year now, 2017, was a suggestion that the VHI's efforts to improve and to expand to include a greater proportion of records as accessible by the participating providers was perhaps impeded by the model of consent that we use, which is an opt-in policy. As of that time, the health records of only 19 percent of Vermonters were accessible in the VHI well below what would be considered useful to providers who use the exchange. So in the following year, Act 187 was passed, which charged the Department of Vermont Health Access with the undertaking of examining the issue and consulting with stakeholders and making some recommendations to various legislative committees about whether or not to continue on with opt-in or to consider opt-out. Just to make sure we're all using the same language in the same way, just want to pause for a second and talk about what we mean by opt-in when we say that term or opt-out. Opt-in presumes that consent is withheld unless stated otherwise, and for the VHI, this means that a patient's records are accessible only if a patient expressly indicates that I want my records in and accessible. Opt-out presumes that consent is granted unless stated otherwise, and for the VHI, this would mean that a patient's records are accessible in the VHI unless the patient expressly indicated that they didn't want their records to be accessible. Both mechanisms are valid ways to express or withhold consent. I don't think there's any real debate about whether or not these mechanisms are valid or invalid one as compared to the other. There are just two different ways of getting at the question of whether or not an individual wants to consent or withhold consent to some question. We started our examination of the issue by looking at what some other states are doing in this area. Health tech, when it assessed the VHI in 2017, also was making its recommendations in light of what it has observed to be successful exchanges in other states. We thought looking at what other states are doing in this area might be illuminating. When we did, we quickly found that the vast majority of states that have statewide exchanges either have opt-out consent or no consent requirement at all. You might ask, well, how could they have no consent requirement? The simple answer to that is that federal law governs how healthcare information is accessible and exchangeable and communicable among parties. I'm sure most of you have heard of the privacy and security rules under HIPAA, which squarely address how health information can be shared between healthcare system participants. The states that don't have state-level consent policies just default to the protections that are already existing in HIPAA. So it was 43 out of the, excuse me, 33 out of the 41 states that we identified as having statewide HIEs, health information exchanges, use opt-out or no consent at all. Four further ones use a combination of opt-out with generally, but with opt-in for specific types of medical information that might warrant a more restrictive approach or with respect to certain populations like private insurance-covered individuals. Only three states besides Vermont use a Vermont-like opt-in model. It's worth noting that Health Tech Solutions, in its evaluation of successful states for the purpose of comparison with how Vermont was doing, showed that all nine successful HIEs that they sort of lifted up as models for success use opt-out, and some of those states use opt-out models that create even increased barriers to opt-ing out. So create a stronger presumption that records are shareable within the exchanges. Which brings me to my next point. As we looked across the nation at how states are doing this, the vast majority of them are using opt-out, and they're not all the same flavor. Part of the reason we were doing this inquiry is because Vermont law requires the standards that are adopted for the exchange to be in alignment with national standards. So we were trying to discern whether or not there was a single national standard. While there was some variation and not all states huge to a single standard, obviously the vast majority of them used opt-out, and the different sort of levels of sort of stringency were defined by what process was necessary to express your intention to opt-out as an individual. Some made it easy for individuals to opt-out by providing online options. Others had to be paper forms, had to be submitted by fax. Others further restricted it to require notarizations or provider counter signatures on their forms of election to opt-out. Four of the states among the nine successful HIEs require notarization, so that creates a strong presumption of record inclusivity in the exchange and exchangeability. After, yeah, of course. Thanks, Steve. Michael Costa, deputy commissioner of DEVA, and I just, as Steve goes through as our general counsel and kind of gets you through the weeds of where we've been and where we're going, I don't want to lose sight of a bigger point. We came before this board and the legislature starting in 2017 because the HIE program was not performing very well. We have done everything we can to try to maximize our chances for success in HIE as a program and as a driver of success and innovation in health care in Vermont. And that's been a combination of things. We've tried to provide more leadership, grateful to Mike Smith and folks at Vital who've stepped up and tried to be good leaders of that program, grateful for the board for considering and approving the HIE plan at the end of last year. We've tried to be more focused and do a better job of saying what we want and why we want it. And now we're trying to have a real focus on execution. We've done everything the legislature has asked of us through very Act 73 and Act 187. And we'll see if we're able to execute on the tactical plan that was included in the HIE plan you approved. Through that inquiry, thinking about what are the type of things that will maximize our chances for success in HIE, I would say, for my own opinion, the experience of consent policies in other states that Steven just described sticks out like a sore thumb. Vermont has clearly has a minority position on consent. We are doing it differently than almost every other state and particularly different than states that have had some success in HIE, according to national experts. And so the question is the big picture policy question is why? What benefit are you getting in exchange for having a minority position that, in my opinion, has served as a headwind for having access to records? And so I think it's appropriate now to go back to Steven and get through what's going to be in our report, which is due to the legislature. But I just don't want the bigger picture issue to be lost as we do that. Clearly, I should have let Michael speak first. Much better framing of the issue than I did by just launching into things. But with that said, I will continue forward. So we talked to stakeholders who are reflected on the slide here. For those that may have difficulty reading it, we spoke to Vital, which is the operator of the VHIE, the Office of Healthcare Advocate, the Green Mountain Care Board on a number of occasions. The ACLU of Vermont, Vice State Primary Care Association, which represents the FQHC community. The Vermont Medical Society, Vermont Association of Hospitals and Health Systems. The Medicaid and Exchange Advisory Board, which has a number of constituents across the healthcare system in Vermont. The Primary Care Advisory Board, more informally. And the DIVA HIE, HIT Steering Committee, which has representation from Private Pay Insurers, the Vermont Single Accountable Care Organization, Vermont Care Partners representing the designated agencies, and so forth. So it was a broad outreach effort. And the outcome was that the vast majority of stakeholders, support opt-out, for many of the reasons that Michael described. They generally believe that it supports increased accessibility to records. You know, the administrative burdens under the existing system are necessarily manual and cumbersome. And as a consequence, they, you know, providers just don't ask for consent. And it's led to an unacceptably low number of Vermonters even being asked the question of whether or not they want their records in. They observe that of the people who are asked, 95% of them indicate they want their records in. So they feel like a system of consent that presumes inclusion is more in alignment with the desires of Vermonters on the issue. And they're comfortable that, you know, switching from one consent policy to another or one model to another wouldn't in any way degrade patient privacy and autonomy, you know, in some ways, you know, to the contrary. And I'll go into that a little bit more in detail. Stakeholders opposing the change were limited to. It was the Office of Vermont Health Care Advocate and the ACLU of Vermont, both of whom expressed a desire to stick with the current policy. The healthcare advocate didn't really go into detail about the underlying reasoning supporting their position. We tried to understand how they were balancing privacy interests against the healthcare interests of Vermonters, which arguably would be supported by a high-functioning exchange. But there wasn't much that we learned as we tried to get clarification around that. But the ACLU also preferred to stick with the policy like the healthcare advocate. They shared a sort of a generalized notion that moving to opt-out would somehow be less protective of privacy and autonomy than sticking with opt-in. Although, again, it was difficult to understand exactly how that conclusion worked. The ACLU, though, I think sort of understands that, you know, which way the wind is blowing and that across the country systems are recognizing the need to use an opt-out consent if they choose to use one at all. And they focus most of their comments and feedback on sort of the practical considerations of how we would implement a switch to a different system, you know, wanting to ensure that there was, you know, multiple instances of notice, patient notice and publicity around it, you know, rigorous provider training, an implementation plan with plenty of time for anybody who wanted their records to be excluded to, you know, to take the action necessary before the effectiveness of a switch. So one of the things that there were a couple of themes that kept coming up. One was this, you know, this idea, you know, is security of health information some, would it be subject to compromise or weakened in some way under a different policy? Other questions came up about what are the legislative implications, if any, to making a change? And what fundamentally do most homeowners want and is our policy aligned with that? Um, relating to security and, you know, having consulted with the experts who operate the VI, it's clear that the existing security features in the VI are robust and they meet all of the applicable requirements for security and that changing the model of consent would have absolutely no impact whatsoever on the security features that protect information reposed in the VI. No system safeguards would be altered in any way. So it's a little bit of a, it's a little bit misleading to think about a change in consent as having any impact whatsoever on the security of records within the system. Relating to the question of whether or to what extent legislative action might be required, our analysis determined that there's no Vermont statute that governs whether or what kind of consent would be required from a patient for their records to be exchangeable as contemplated within the within the HIE. Some folks have argued in the past before there was a little bit greater clarity in the law, and I'll get to that in a second, that the patient privilege statute in Vermont, which is a Title 12 statute, you know, conferred some some manner of broad medical records privacy rights on Vermonters. The Supreme Court in 2016 clarified that that is just not the case, that the the scope of that statute is really limited to judicial proceedings only, and it is it does not confer a broad right of privacy and medical records beyond judicial proceedings. It really and that also sort of squares with the plain meaning of the statute, which is about qualifications of witnesses to testify at trial. There are also some some folks who've over time thought maybe the involuntary mental health hospitalization statute under Title 18, you know, may require some form of express written consent. That's inapposite as well. It's reading it too broadly to to to think that it would require patient consent generally and the kinds of records that are addressed by that statute are not in the V high anyway, and in order to we plan them to be at any point, at least for the foreseeable future, while we address some, I guess, technical constraints. The only source of authority for this for this policy is in the Green Mountain Care Board and an agency of administration approved policy on patient consent. I'm not going to read the whole title of it. It's a mouthful. But that policy, which the board in connection and in conjunction with the agency of administration has the power to change is is where the the model resides, the consent model resides. What the Green Mountain Care Board can enact into policy, it can change as well. You know, this this policy, you know, under the the statute that governs the Health Information Technology Plan is incorporated into that plan. And it's important to remember that the the the title or the statutory provision that that requires the development of standards around privacy requires them to be in alignment with national standards. So bottom line, no legislative action necessary. The other the other point that kept coming up is is, you know, what about what about the people? You know, we have these conversations about consent and sometimes we we tend to forget that it's been demonstrated time and again that the vast majority of Vermonters not only want their information in, many of them assume that it's already in and accessible. As of late December of the two hundred and seventeen thousand Vermonters asked over ninety five percent want their records accessible in the V high by other providers who may have, you know, occasion to treat them. That means that about sixty three percent of Vermonters have not even been asked in large part because of the administrative burdens and costs associated with the current opt-in policy. None of their records are exchangeable in the V high under opt out records of approximately two thirds of patients would be accessible upon implementation of a new policy, which takes us into, you know, the range of of critical mass of records accessibility. That's the hallmark of high functioning exchanges. I know that, you know, we've tried to be really transparent in our thinking and our process here. And what has come up several times when we show this statistic is hey, if ninety five percent of the people ask, say, yes, you just need to ask more people. And what I would say to folks is, hey, look, we are asking for a lot out of primary care providers and other health care providers in the state. We've got Medicare commercial insurers and Medicaid asking them to do things. We have the blueprint asking them to do things. The ACO asking them to do things. Various quality reporting measures. You know, what is getting by spending time and effort trying to modify the administrative process regarding consent when the experience of other states by and large is to just create an opt out. So just simply show me the value in spending time optimizing that process compared to myriad other things that we could be asking health care providers to do, not least of which is spend more time with your patients and less time on administrative burden. The final thing I would note is that, you know, if we care about patient autonomy, which we do, you know, one way to look at that is to ensure that our policies support the implementation of the wishes of the most Vermonters. What's clear is that an opt out policy would be, would produce results much more in alignment with the will of the vast majority of Vermonters. And also, it would more than accommodate the wishes of those who desired to opt out. In either case, you know, either transaction opting in or opting out requires the engagement of the person making the choice. Whether they implement that choice by doing something or electing not to do something is, you know, doesn't determine whether, you know, the validity of their consent. They're both equally valid mechanisms. One gets us a lot closer to reflecting the will of Vermonters than the other. So it should come as no surprise that our preliminary recommendation as we've thought about this, you know, over the past many months and had all these conversations with the health care community is that we will be recommending the implementation of an opt out consent model in replacement of the current one, which has proven so lacking in so many significant respects. We, in doing so though, we can certainly take into account some of the concerns of those who oppose a change by number one, making it really easy to opt out in whatever policy we develop. And, you know, supporting that with whatever we need to. For example, you know, to, we would recommend, you know, no hurdles of notarization or provider counter signature or things like that and try to make it as easy as possible. And we would implement it in a way that allowed for a long lead time to ensure that anybody who wanted to be out was informed, had actual notice, had an opportunity to consider what their wishes were and had the opportunity to implement that before the change took effect. That said, our final recommendations and report won't be submitted until next week. And we came here in part today to hear if there was there any, you know, other thoughts out there that we should consider as we formulate our final recommendation. So with that, I'll ask the board or I don't know how you solicit audience. So we first go through the board questions. Okay. We turn to the public. So members of the board, do you have any questions? I have a question in the comments. On the previous slide, first of all, thank you for coming and it's good to see you here. On the previous slide, you indicated approximately two thirds of patients' records would be accessible. Who are the other one-third? Or can you talk a little bit about the one-third that would not be accessible? I really wish Emily were up here because she knows the identity of that one-third. Yeah, can I? There she is right there. But that figure, I'll just say in turn, Vital wants to respond. It's based on the previous data point that Vital gave the pre-medicine board a couple of years ago, about 65% of Vermont's patients were accessible in the beehive. So I'm sorry, I will call myself turned to Vital, but I think we all know that not every provider can access an electronic health record, so it's not always going to capture every single patient, and just not every single patient has either stated position that's connected to the beehive or a single position at all. So we're always connected. Well, so if I may, if I may, Emily, when we think about success, we think of a numerator, which is how many individual Vermonters records are accessible in the beehive, and a denominator that is all Vermonters. Changing the consents policy is not a panacea, but it is progress, and our hypothesis is that changing it would allow us potentially to get that numerator to a place where about two-thirds of Vermonters would have accessible health records in the beehive. Five misspoken, feel free to. All right, all right, all right, all right, all right, all right. I'd like to know if there's a difference about the presence of the beehive. Remember, we have about one variant in the beehive. Yep. So the two, there's five, and one there. Is that a half percent? Mm-hmm. Got it. So what explains it, just to recap, if the recording didn't catch it, is providers who don't have electronic health records systems or who may not be participating in the beehive, patients of those providers represent about one-third of Vermonters. So respecting Michael's point, the denominator is all Vermonters, but if the denominator were those that we could reasonably expect to be in the exchange, we'd be doing a lot better than 65% by changing the policy. Okay, and certainly even with this change, it doesn't impact the federal rules around part two information. So even if that person's consent was assumed under a change in the policy, that protected data would still remain protected. That is correct. Part two records are not in the beehive, and nothing in our recommendation addresses part two information. We're sort of proceeding on a status quo basis relating to part two, and hopefully that problem will be solved at the federal level when they see fit to conform part two in greater alignment with what HIPAA provides. Thank you. So my comment is, I just wanted to say personally that I like the opt-in. I know we're not necessarily discussing or making any decisions, but just in terms of giving you feedback, I personally think the opt-in is the right, I mean the opt, yes, I'm gonna confuse myself. I think changing the policy makes sense so that we are opting in, so that there's an opt-out. Thank you. But to me, part of that is tied to what Vital currently does today, and certainly under their new strategic plan, there are some new areas that they might be looking to expand into, and some new private partnerships that obviously at this point are unknown. But I think for me, part of what has to be clear is what the data can and cannot be used for, and I personally do not feel that HIPAA is sufficiently protected because it does allow the sale of de-identified data for profit making purposes. And in the past that has been used, then specifically the clearest example I have is by pharmaceutical companies to re-identify the data essentially, and then use that to change provider practicing behavior. So I do think there are some privacy issues. I agree the security is good. I don't think there are security issues, but I think that there could be privacy issues if we stuck with a HIPAA-type model, and there weren't additional considerations there. So that's my feedback for you, pick or leave. I appreciate your feedback, and I would just respond by saying that in addition to the requirements of HIPAA, the V-HI itself and Vital has adopted policies that place further constraints on the use of the healthcare information within. I'm not certain about what the parameters are around the use of de-identified information, and I guess I won't assume, but I think that we have room to work to address your concerns if indeed our policies are falling short in any respect. Absolutely, I agree. It could certainly be addressed in a consent policy document. So that's partially why I wanted to say it out loud. Sounds good. Thank you. Other questions? I just had one on, I mean, I think it's a really compelling case to do the opt-out. My challenge would be if we think it's gonna be easy for people who do want to actually opt-out. I mean, this option is compelling, but we're saying we're gonna make it easy for them to be able to opt-out. Someone could say, why wasn't it easy for them to opt-in when we wanted to do it? And I know we've had a real struggle getting people to opt-in, and I just think we have to be really careful saying if people want to opt-out, it's gonna be easy to do because the devil's advocate would say, well, then let's just make it easy to opt-in. He's probably, so. That's a really good question. I'm not sure why it's so hard. All I know is sitting in my position as the administration's executive sponsor on HIE is that we've had this policy for a number of years and it hasn't created the scale and participation that we would like. Potentially there are a lot of reasons why and I don't know them. I just know that the proof is that we haven't got there. I think when it comes to making sure we have the appropriate opt-out policy and we share your concern that it needs to be effective and it needs to be easy, what I would do in working with other stakeholders and with the board is to, for example, take something like our ACO opt-out policy, which we presently administer and we think it's run fairly well and say we would try to make something as easy as this. You know what particular concerns do you have as regulators or advocates or other members of the public with that process? So for example, in the ACO opt-out, we send, just this past week, we sent letters to over 40,000 Vermonters and gave them clear instructions on how to opt-out and a small number will take advantage of that and so we'd be happy to propose some sort of straw model and get feedback on how folks think that should work most appropriately. I would add to that that even if the implementation of opt-out, the administrative sort of back office burden is the same per transaction, the fact that there are likely to be, we're sure to be so many fewer instances in which a provider will be called upon to do anything at all. Out of every 100 patients they see, only four or five are gonna be exercising their opt-out rights. That's something that is welcome news to the provider community and I think they're much more likely to participate in giving effect to the consent policy if it only asks them to do something four or five times out of 100 rather than 95 or 96 times out of 100. Okay, thanks. Other questions? I guess I would first of all say you pretty much had me at hello because I'm a strong supporter of revising the consent policy with some of the caveats that have already been mentioned and how the data is used and actually how somebody can opt-out but I thought I'd just give a little, and for people who don't maybe know this literature there's plenty of literature in the field of behavioral economics that actually talks about people have a default bias so no matter what the default is people will find that more attractive and even experiments that randomly assign what's the default, people will go to the default and so whether there's economists have speculated that that could be some sort of cognitive difficulty in changing away from the default it may be that people just believe that whoever has designed the model or the policy assumes that the default is better so they're the easy way out. There's lots of economic reasons for why people choose the default but it's well known in the literature that whatever is the default is what people are gonna, you know, are biased towards and you can look at a really prime example of this is organ donation. So you look at a country like Germany that has opt-in as we do in the US and only about I think the number is 12% of people opt-in to donate their organs you flip that and you look at Austria that has opt-out and 99% of people consent to donate their organs it's a huge swing and there's plenty of other examples in policy around how people opt-in and opt-out of even savings, retirement plans through the workplace, change the default and it changes behavior very, very significantly so given the concerns that we've had about the beehive and getting folks enrolled or consented into the beehive, their data I'm a huge proponent of this and I would say so it's great to see that we don't have to necessarily go through a long process to think about if it's an agreement and care boards consent policy I would say let's explore that from our end because clearly opt-in policies have been proven costly and ineffective and opt-out would be I think the way out to get more people into the system and I would also just say people do get confused opt-in, opt-out, it is very confusing it's easier sometimes to just say presumed consent presumed consent is opt-out and that's just easier to remember it's presumed consent and presuming that you consent so anyway I just might throw that out there that people are having trouble remembering and maybe easier to use presumed consent as a language so it's a huge supporter and I'd like to see what we can do Super so a couple of questions in your research for the report you mentioned a number of states have no consent policy can you tell me if there have been lawsuits in those states that have been quite contentious or if there have been any adverse effects to the individuals who are subject to that ability to declare what their true intention is Yeah our research did not flag any increased incidents of sort of bad outcomes to use a sort of generic way of phrasing it in states that didn't have a state level consent policy and certainly the same is true for opt-out we didn't see that data now that wasn't a primary focus of our inquiry and so you know I would have to go back and hone in on that to give you a more definitive answer At this point we're going to turn it over to the public for any comments if you could stand up and say your name and then address your comments through the board Yep you I hope I can be heard without a microphone is that alright? As long as you keep up that volume we can do it Thank you So for the record my name is Kirsten Murphy I'm the executive director of the Vermont Developmental Disabilities Council I would say upfront that I don't enjoy disagreeing with Mr. Costa I usually agree with him and we offer these comments in a spirit of trying to make your health reform effort successful For context the council is composed of 60% individuals with developmental disabilities and their family caregivers developmental divisibilities are significant lifelong conditions and impact 18.4% of the population are roughly one in five Americans Councils exist in every state and territory with the federal mandate that we advocate for policies that advance the independence productivity self-determination and community inclusion of people with developmental disabilities what's at stake for us today is the self-determination component the right of people to whether they have a developmental disability or not to make decisions for themselves and not be compelled to into decisions The council is concerned that a shift to an opt out consent policy with degrade patient privacy for the population we represent which generally has a low level of health literacy shifting the burden from provider to consumer would compromise the ability of people with developmental disabilities to make an informed decision about their personal health information I have a few specific points One would be the need for broader stakeholder input In my review of the current consent policy it's my understanding that protected health information subject to the Green Mountain Care Board policy includes mental health communication and might in the future even include substance use disorder Now since these are unfortunately stigmatized conditions it's reasonable to assume that consumer groups like NAMI or the Vermont Association for Mental Health and Addiction Recovery might have concerns The list of stakeholders consulted by Diva didn't happen to include any such group In fact most of the groups listed on slide six were provider groups, not patient groups and that oversight should be corrected I also feel that today's presentation downplays a little bit the concerns that were expressed by some stakeholders I spoke with the director of the ACLU yesterday and I have his permission to say their position is unequivocal an opt out policy compromises Vermont's right to privacy and citizens should not have the burden of opting out of opting out imposed on them for the convenience of providers I was present for the Medicaid and exchange advisory boards meeting and the issue was the group was so sharply divided we weren't really able to make a meaningful recommendation Second it's somewhat misleading to claim that opt out better reflects Vermont's intent Opting into the HIE is not the same thing as signaling support for an opt out approach as is claimed on slide 11 just because someone chooses to opt in does not logically mean that they don't want to be asked about their preference Third point indicators to date signal that consumers are likely to be confused by or uninformed about their options and an opt out approach and with all respect to the good work that Vital does they may not yet have reached a point of being fully consumer friendly but the fact that provider reluctance to engage consumers in an opt in scenario indicates that they would be an unreliable point of contact for consumer engagement in an opt out scenario so simply put if providers are burdened by asking patients to opt in which is in the provider's interest how likely will they be to inform consumers that they have a right to opt out which is not in the provider's interest today's presentation noted that it should be easy to opt out and the implementation of a change in the policy should be managed with care I would urge the Green Mountain Care Board to not agree to a change in policy with first reviewing a compelling plan to ensure that consumers understand their options I have a hard time seeing how such a plan would not still impose some level of burden on the provider since it does take time to explain someone's right to opt out as it takes time to tell them that they can opt in I would also note that the processes currently in place for consumers to navigate decisions about their health information are already somewhat confusing and burdensome the brochure that families can look at or people can look at is not something my constituents would understand the forms are confusing and have to be cosigned either by your medical provider or by your notary if you choose to change your mind if you want an audit or if you want to look at your own protected health information so I think that there is work to be done in becoming more user friendly especially for people with a broad range of health literacy levels I want to dispute a little the fact that there is a sort of national consensus on this there are other states that have been successful in implementing an opt-in policy today's presentation indicated that Vermont is only one of four I would not going to quibble with any number but some states that are opt in states are states with large complex health systems like New York and Florida I note that an oppress release dated July 27th of 2018 representatives from New York's eHealth Collaborative announced a very successful 10 month campaign that netted 8.8 million patients who affirmatively gave their consent to participate in data sharing across the state wide health information network authorities touted the opt-in approach as showing quote higher levels of patient engagement with patients taking the initiative to facilitate better health data exchange between themselves and their providers Florida's health information exchange seems to be having similar success with articles in the press reporting more than 6 million Floridians opting in Vermont might consider having learned from successful opt-in states finally I want to note that Vermont is really making solid progress using an opt-in approach so as you heard in the presentation in November of 2017 in the evaluation of Vermont's health information activities the health tech solutions report only about 19% of people were opting in 20% were asked and 19 opted in but more recently on January 1st of this year so just a few weeks ago Vital delivered a progress report to your board and to the legislature that indicated a significant increase in the statewide ask rate in fact Vital now exceeded its target with 3.8% of Vermonters opting in and the trend has been solidly in the direction of greater patient engagement and consent how has Vital achieved this significant improvement and could Vermonters do more of what has begun what is being described as provider burden is a concern but one that is outweighed by the need to protect the patient's right to determine an acceptable level of privacy let's remember that in virtually all cases consent is solicited at the reception desk not in the doctor's exam room soliciting patient consent is part of delivering fully integrated care it's an opportunity to engage individual Vermonters in our state's new approach to health care in closing I urge the Green Mountain Board to proceed cautiously and I hope we'll ask additional questions wait for a full report the full report required by Act 187 and take further public input before making any change to your policy I'm happy to give you the written copy thank you other public comments or questions yes this one describes me as complex and as they were described and opt in and opt out I couldn't help but think of getting my morning cup of coffee sitting down on my computer this morning and this little screen pops up and says I want this news for an hour I click both buttons on my mouse I hit every button on my keyboard it wouldn't let me do a thing and I don't know what this news for an hour is about I didn't know if I clicked that yes if it was going to fall asleep for an hour when I'm ready to do some work or nothing happened I got to use it I don't know what I agreed to I have no idea all I know is it wouldn't let me do anything unless I paid attention to that little screen saying it wants this news for an hour this is a little bit like fast opt in or opt out no matter which one you've picked one feels better than the other I didn't like that feeling this morning of not being able to do anything in a sense unless I agreed I had no idea what I was agreeing to opt in if I don't get confused means I have to choose before anything happens that as a consumer makes me feel better than my computer made me feel this morning here's another Michael I'm going to same thing I don't totally agree you're trying to work a denominator and a numerator and you're trying to get your 20% so you've got enough people to say you you have sufficient participation how I would go about doing that from their perspective is not what I think really does respect the consumer I just listened to Mitzi give her a speech this morning and in that speech she said let's remember to respect all Vermonters I don't think this policy will do that and that has me greatly concerned it doesn't matter that the majority of Vermonters would be in what matters is every population being respected which includes if by numbers it's a minority population that doesn't matter are they going to be respected is meaningful a healthcare system that doesn't respect all populations is going down the path that I have talked about before this worries me people getting siloed sidestepped step on disrespected not seen for their real needs as far as their medical needs and therefore disrespected I can do that with the measures as well if I arrange the measures to look at only certain things I can have a whole population out there that might measure as being successfully given what they need and they didn't get what they needed because the thing that they really needed besides what they did get never going to measure so I almost think this should go before the legislature and actually have a more in-depth look at it because there's more profound issues here that you're considering I think you're very capable of considering this issue I'm saying I think it involves so many Vermonters because it involves all Vermonters the board should consider it's that big an issue that it should go beyond the board and I will leave it at that my name is Sam Bliss and I'm actually a member of the newly restructured Remount and Care Board General Advisory Committee and I was literally asked at the last minute the president of Vermont Coalition of Disability Rights to represent BCDR at this public meeting BCDR comprises approximately 20 disability rights organizations rather than repeat everything that Kirsten and Dale have said on behalf of BCDR I just wanted to concur specifically with what the Executive Director of the Developmental Disability Council said in terms of concerns especially for those that are not as health literate as other people might be I myself have full confidence in the Green Mountain Care Board but I did want to share with those concerns in terms of making sure that informed consent is required to everyone and is sustained I actually find this very troubling and I must admit emotionally triggered by your comment about Austria and the opt-in in terms of organ donation you know these are things that I doubt very much that everyone who is on the list of organ donation in Austria really feels that they've been fully informed whether they really want to be there or not and again I have emotional reasons for feeling that way that I do believe it should be an opt-in I also feel that way in terms of this and it has to do with informed consent the fact is that I have trouble as a provider of addiction medicine services getting information on my patients because of HIPAA from other doctors and other nurses as a result and I find it really troubling that this information can be gotten just by a panel of how many I agree I think this needs to be done by the legislature and I strongly urge you to leave things as they are this idea of opt-out to me is very anti-democratic I think it's against the freedom and rights of individuals and it's very disturbing to me Any other comments Eric? My name is Eric Schultes with the office of the health care advocate so I have a question and a comment could we go back to that slide with the title 96% of Vermonters want their records accessible so was the 217,000 Vermonters who were asked was that a representative sample? I'm not a statistician but I think that a sample of 217,000 out of 600,000 is likely to meet the threshold Okay, so I'll grant that the end so the number of people asked is high but if it's not representative it's factually untrue to say 96% of Vermonters want their records accessible as is opt-out better reflects Vermonters intent that's marketing not truth I think as we talk about this we should think about what numbers actually mean and you can't make an inference about a population of 600,000 from 217,000 people if it's not a representative sample So if I may Mr. Chairman just since we're invited to respond to a question just going back to Ms. Murphy's public comment I always really appreciate your comments because part of my time at the agency of human services has got me to think about the phrase integrated continuum of care not just as the thing we talk about but hard work we do every single day and so I always appreciate your comment and then when I took this job Secretary Gobe only told me two things one, do the right thing and two, don't kick the can down the road and so we've not tried to mislead anybody we're happy to update the slides to soften the edges of them I think we tried to be clear with the ACLU that they said no, but we heard it as no but here are the good things you should think about if this policy is going to be changed and to the extent some of it seems you know reaching a little bit, we're happy to change that but the second part of what Secretary Gobe told me was don't kick the can down the road I cannot look at the IE experience of the majority of states and believe that opt-in remains the most effective way to operate the program and to maximize our chances for success and protect the public investment that went into it I very much appreciate that people will disagree on this point but I just want to be very clear about sort of my viewpoint on it and the fact that we will take these public comments to heart is we craft the report presumably the next slide deck that will go in front of other public policy makers so Eric and others thank you for that feedback so I think doing the right thing in this case is basing this decision on what folks want and I think that is doing a representative sample so it's not to say you guys are doing wrong it's just let's hear what Vermonters actually want, let's hear what patients actually want and let's craft an instrument, a survey instrument to get at this and it is a complicated question and we know we can get answers to complicated questions by looking at the health information household health insurance survey and I don't see that in this presentation the comment is I'm sorry that our office's input wasn't useful to you we would be happy to talk in the future about that I want to clarify some of our concerns with the hope that we can move past the it wasn't useful comment one is I think we share some of the board members concerns that if opting in isn't done right why should we think opt out will be done right like if you can't process opt ins at the provider's office why would you be how are you going to be processing opt out this is somewhat of a personal problem for me but if you think the main causal reason for not having more participation is burden on providers or somehow them not being able to process this correctly it seems to me that the solution should be addressing that causal problem and not putting the burden on consumers and that is another so that's one reason why we're concerned we see the issue we think the solution should address the issue and not simply put it on the backs of other vermanders thank you there are other members of the public comments or questions I just have a request which is that it seems like there was a lot of progress made in a very short amount of time from like 19% of records in to over 38% of records in a short amount of time so I would just request that the board invite vital to present well what did they do in that less than a year to nearly double the records because if they did more of that then maybe they figured out a way to address the provider burden or whatever the obstacles were all of a sudden the heat was really turned up and to really good effect and so I don't know that this Green Mountain Care Board has enough information yet because something seems to be working we don't know what that something is so I would just request any additional hearing to get more information well this is not a hearing for this board to make any decisions we're hearing the report we make that perfectly clear I think there have been some strong arguments made and I almost flip it the other way when I listen to my good friend Sam and he's saying that he believes that the community that he's representing would have a tougher time with an opt out policy I think that they actually maybe denied the quality of care that they're entitled to with an opt in policy and those are the type of things that you know people think that there's this reception area that is there for each patient that walks them through this opt in policy and the reality of what we're seeing is that isn't occurring I can tell you I go to one of the few doctors who doesn't even have a receptionist probably not a wise decision on my part but I doubt that if I was in an accident someplace that my information would be available because I've never been asked to opt in and I think a number of the monitors are in that very awkward situation so this is not an easy thing as we move forward and just caution everybody that we should work together for a good solution I don't think anybody's rights are taken away whether it's opt in or opt out necessarily it's just that it's a different form of burden so you would still be able to protect your information if that was your choice Hi, Joseph Barnard on behalf of the Vermont Medical Society so our members are physicians and physician assistants across the state and so we are on the provider side of things but I just I do want to weigh in to just thank Michael and Steve for their work on this presentation what we have heard from physicians and one of the frustrations to Michael's point about sort of the future of the VHI do we think this is actually a system that can improve the health of our state and that it's important when you go to multiple providers for them whether when we have low numbers of participation of patients at least on the vital access side I think physicians get so frustrated they don't even use the system if we only have whether it's 19%, 30%, 40% the chance that they go in and find useful information on their patient is so low that they may stop using it altogether and then this isn't serving anyone and whether you've opted in or not opted in so I think the point that I would like to make is I really do our members, our physicians really do want to see progress on this they want to see more records in or I shouldn't say in but consented to be viewed and that's another point I just want to highlight and the board may be well aware of this but these records are in this the information is in the system and to the point about security it's just whether the other providers who are taking care of you can see it so if we think we want the hospital if you're hospitalized on an emergency basis to be able to see this information and that that is for the good of the health of our state our members would like to see a change in this direction so thank you for the work of Diva we really we do support the presentation today Sure, Mike Smith, interim president, CEO of VITAL I do also want to thank Diva for all the work that they put forward we supported the study we also support a change in consent policy and let me tell you the reason why currently medical providers can only access a minority of Vermonters records here in Vermont changing the policy would mean that they'd be able to access a majority of the patient records in Vermont with all the safeguards that are in place I've heard a lot of the things and I heard Michael talk about kicking the can down the road and many of you know I don't like to admit mistakes but I made a mistake in 2006 I kicked the can down the road I wish we would have addressed this issue in 2006 when the VHI was established and we went to an opt out policy during that time I think it has hindered the progress of the VHI over this many years you know I've heard some talk about a communications plan and I think that's critical by the way if we go to this policy on a communications plan to make sure that all people know what's going on and I'm committing vital to work with Diva to establish a communication plan that will reach out to people on this change of policy I've also heard statistics about other states you know when we talk about 6 million in Florida for example that's 6 million on 21.3 million of people that's about 28 percent that's not that isn't success in my mind we've had success and I want to address that we've had success this year because of what has happened with the Green Mountain Care Board integrating sort of the budget process with the consent policy electronic consent policy that we implemented a year ago that consent policy has had success in terms of elevating from 19 to 38 percent for consent I have testified in front of the Green Mountain Care Board I firmly believe that will plateau at some point we are going to be at a point where it's going to plateau and that means that we've had success up to a point in order to gain further success I really believe that the opt-out policy is the is the policy to proceed so I thank Diva for all their work I do agree that we need a communication plan that incorporates some of the fine comments that have been made here and I would urge the Board to approve a change of policy thank you other members of the public if not, Jess I think you had a question actually I was going to ask well I was going to ask you but I wasn't sure if you'd be able to answer but I was going to ask about the impact that the Board's decisions around the hospital budget asking each hospital to work with Diva and I actually just want to say that one of the things that I love about being on the Board is the public comment that we get so I just really want to be appreciative of Deb and Sam and Kirsten, Dale, Susan your comments around the impact that you see it and I hear you so I just want to let you know that I'm listening and I hear you and you know I can read the literature and think about things from a behavioral economist's kind of perspective but I hear what you're saying and it causes me to think so I'm telling you thank you for that so thank you everyone very thought-provoking conversation and we look forward to how the report is received in the legislature that this will be a topic at some time in the future that we will be discussing again thank you Michael and Steve at this point we're going to Thank you Mr. Chairman I just wanted to briefly mention that we will do our best to reflect the additional comments that we heard today in our report and account for those in our recommendation So at this point the next item on the agenda is the Household Insurance Survey and we'll give a couple minutes as we invite the new panel down we look forward to this presentation it's always very helpful to see what percentage of promoters actually have insurance and the other problems that we face in that area so if you could start just by introducing yourself and whenever you're ready proceed Alright I'm Jesse Hammond with the Health Department I'm the Public Health Statistics Manager I'm Paul Meadow I'm an Epidemiologist and Public Health Analyst with the Department of Health So I we're sort of splitting the presentation into a couple of different pieces and I'm going to give a little bit of background and introduction as well as start to talk about the results with the Health Department took on implementing the Health Insurance Survey with the 2018 version of the survey previously it had been implemented by the Department of Financial Regulation so in some ways this was a really interesting and unique opportunity for us to work on a project where the content isn't necessarily something that we focus a lot of our efforts on we do a lot of surveys and data collection so that's sort of the angle that we're coming from the the why part is a little bit trickier for us and we would defer to some of our other partners and this has been a really great opportunity for us to work with some of the partners in state government that we don't necessarily get to work with often so that all said the Health Insurance Survey has been done since 2000 and one other thing I should say with the Health Department taking it on we tried to keep a lot of the methodology similar for comparison's sake and we also used the same data collection contractor that it had been used in the past who has great knowledge and expertise in data collection but also in Health Insurance type surveys specifically so they were a great asset to us in completing the survey this year's version was conducted, data was collected from January through June of 2018 and we reached 3,000 households and about 7,193 people it was a random digit dialed telephone survey on cell phone and landline telephones to make sure that we captured the full population and then the data were weighted to be representative of all Vermont residents and something that's a little bit different than had been done in the past we in presenting the results suppressed data where the unweighted numerator so the number of respondents was less than 5 and or the denominator was less than 50 this hadn't necessarily been done in the past but the Health Department this is a fairly consistent policy for the Health Department it both protects confidentiality of any respondents and also when sample sizes are small results can be more variable so it helps protect the quality of the results as well so first just talking about overall insurance quality insurance coverage I don't know anything about quality so since 2005 the insurance uninsured rate has gone down by more than half in 2018 3% of Vermont residents were uninsured according to the survey during that same time the proportion of the population that has private insurance has decreased while those covered by public insurance sources like Medicaid and Medicare has increased in terms of numbers of people about 19,800 are uninsured 329,800 have private insurance 136,900 have Medicaid 121,100 have Medicare and about 17,000 have military insurance and then we also can look at the data not just by what the primary source of coverage is but looking at all combinations of types of coverage even with the decrease in coverage by private still 53% of Vermont residents have private insurance only a quarter have Medicaid only a lesson one in five have Medicare only and few generally have any combination of more than one type of insurance that excuse me looking at insurance coverage by geography most counties reported an uninsured rate of 2 to 4% in this iteration of the survey the Moille County was the outlier and has an uninsured rate of 11% which is statistically higher than the state it should also note that due to small businesses Essex County and Grand Isle County were not reportable but you can also look at not just the uninsured rate but looking at private insurance where Chittany County has a significantly higher rate of residents covered by private insurance whereas Caledonia and Orleans County are statistically lower somewhat correspondingly Orleans has a higher rate of Medicaid coverage while Chittany County has a statistically lower rate and Franklin and Orange counties have higher rates of military insurance while Chittany County has a lower rate in these first few slides there's a couple mentions of uninsured excuse me and we'll talk more about that in more detail later but generally that those are residents whose policy leaves them vulnerable due to either current medical costs or future ones for the serious medical condition occur but Addison County has a higher rate of underinsured oops making a little bit of a transition here to talk briefly about health savings accounts among Vermont residents 18 to 64 those with private insurance there's similar proportions of these residents whether they are have private insurance or underinsured with private insurance or not underinsured similar proportions of people have health savings accounts and then when you look at contributions to their health savings accounts those are also similar but not necessarily unexpectedly underinsured would have a higher deductible now we're going to move into talking a little bit about the uninsured specifically and we can see here that the rate of uninsured Vermont residents has gone down over time like Jesse mentioned earlier the rate of underinsured in 2018 was similar to statistically similar to the rate in 2014 but it was statistically lower than 2012 and earlier looking at uninsured by demographics we can see here in the graph that the trend of uninsured by sex has also gone down over time but males were consistently more likely than females over all years to be uninsured and then about 10% of Vermonters who are 25 years old to 34 are uninsured where 5% of those 25 to 44 were uninsured of those whose income is between 151% and 251% of the federal poverty level are uninsured and we're going to get into those last two a little bit more detail so this shows the trend in uninsured by age for those under the age of 65 and overall from 2005 to 2018 there's been a significant decrease in the rate of uninsured among all age groups and looking at uninsured at a federal poverty level the rate of uninsured Vermont residents with incomes of 300% of the federal poverty level are less so the top three groups in the graph there had significantly decreased the rate of uninsured since 2005 looking now at some numbers around employment the uninsured rate among employed adults from 2018 to 64 can see that number has also gone down over time the rate in 2018 was statistically similar to 2014 but it was statistically lower than previous years uninsured rates are highest among Vermonters who are self-employed and 8% of Vermonters who work at companies with less than 50 employees are uninsured and just about 3% of those who work are uninsured this is looking at the availability of employer sponsored insurance among insured workers and there has not been any statistically significant changes in the proportion of uninsured workers who indicate their employers offer a health insurance plan this is giving a little more detail on the rate of uninsured by employer size and employers with higher numbers of employees are expected to have lower rates of uninsured so now we're going to look at interest in state health insurance programs and a majority of uninsured Vermonters are very interested in rolling in state health insurance programs you can see that just over half indicated that they were very interested and then another 25% are somewhat interested 40% of Vermonters believe state health insurance programs are too expensive which is their main reason for not enrolling in state health insurance programs and another 21% believe that they are not eligible for state health insurance and then there are far fewer people indicated that it was too much trouble that they had a problem with the application deadline or that they have applied but are waiting to hear back among the uninsured now looking at some people's reasons for not having insurance we're going to start by looking at the importance of cost and not having insurance and half of the uninsured indicated that cost was the only reason that they did not have health insurance and then a quarter have been without health insurance for more than five years now looking at some people's reasons for not having insurance we're going to start by looking at the importance of not having health insurance and another 22% indicate it was one of the main reasons significant decreases there has been a statistically significant decrease as cost being the absolutely only reason for not having insurance since 2005 and the increases and some of the other categories seen from 2014 to 2018 are not statistically significant continuing to look at reasons for not having health insurance you can see that a third of uninsured indicate that they have lost eligibility or are not eligible for state insurance and then a quarter indicate that they can no longer afford employer sponsored insurance and then slightly fewer indicate that someone in their family lost a job and that was the main reason that they lost their health insurance a quarter are simply not interested in having insurance so now we're going to talk a bit about the underinsured so underinsurance is a status that threatens individuals in a similar way to uninsurance while an underinsured individual has an insurance policy the policy may not be robust enough to either cover current medical expenses sufficiently or leaves the individual and or the family in danger of uninsuring medical expenses should a serious medical condition or illness emerge underinsured individuals have insurance coverage so are not taken into account in traditional measures of insurance status however if the root problem of uninsurance is excess exposure to unaffordable medical expenses the underinsured are often equally at risk so to define underinsured persons that have insurance policy but like I just mentioned the policy isn't sufficient to cover their current or potential future medical expenses we identified these individuals by estimating using the commonwealth fund methodology and the link to that methodology is on the slide and can also be found in the report that is available online and under their methodology underinsured is either of the following either current medical expenses excluding insurance premiums are equal to or greater than 10% of the household income if they're at 200% of the federal poverty level or higher or it's 5% of the household income is less than 200% of the FPL or the deductible is greater or equal to 5% of the household income so the reasons more this is looking at the reasons underinsured for being underinsured via the commonwealth fund criteria more insured vermoners face significant deductibles and out of pocket costs or other medical expenses and this rising costs to income disparity has led to an increasing number of vermoners being considered as underinsured and we can see here that overall 36% of vermoners can be considered underinsured according to the commonwealth fund criteria and similar proportions are because of either their deductible or their out of pocket expenses and 7% are underinsured due to both categories and among those with private insurance 40% are considered underinsured 21% because of deductible 8% due to out of pocket expenses and 11% of both so now looking at the actual rates of uninsured over time we can see that among all residents less than 65 years of age a little over a third have indicated are underinsured and all residents with insurance that number is very similar at 37% and then all vermoners less than 65 years old with private insurance so not a lot of variability going to look at some of the demographics related to the rate of underinsured and we can see here that from 2014 to 2018 the rate of underinsured for not residents has significantly increased for both males and females but males and females are both underinsured at similar rates so underinsured by age 18 to 34 year old are certainly more likely to be underinsured than Vermont residents overall all other age groups are statistically similar to the statewide rate so looking at underinsured by federal poverty level the rate of underinsured Vermont residents living at less than 200% of the federal poverty level has significantly decreased from 2014 to 2018 now we're going to talk a little bit about health care utilization so vermoners with insurance are more likely to generally have received service or sought care in the last year across all measures which included visiting a doctor in the past 12 months, receiving a routine medical care, visiting a specialist visiting an emergency room receiving mental health care counseling and receiving substance abuse treatment this is likely influenced by age and other factors that the uninsured population tends to be younger but it should also be noted that this reflects care sought not necessarily care needed so the uninsured as we're going to see in just a minute are more likely to delay care so they may even they're not seeking as much care but it doesn't mean that they don't need it which we'll see that on the next slide so this is just looking at the underinsured versus not underinsured very little difference in terms of seeking care now looking at care delayed in the last 12 months due to cost excuse me the uninsured in the converse to the previous slide about seeking care the uninsured are more likely to delay care across all categories which included dental care routine medical care from a doctor diagnostic test prescription medications or mental health care counseling seeking or delaying care due to prescription for prescription medication and mental health care those differences were not statistically significant I should also say that over time the difference between the uninsured and the insured has decreased the proportion of the insured population delaying care is steady over time while the proportion of the uninsured delaying care has decreased so fewer uninsured are delaying care over time but there still is a disparity as compared to the insured population looking at the underinsured population in delaying care due to cost similar results to the other slide that the underinsured are more likely to delay care than those who have insurance that are not underinsured it's looking at out-of-pocket medical expenses those who are insured are more likely almost three-quarters of them have paid more than $500 in out-of-pocket costs in the last year for medical care while only 6 in 10 of those without insurance and that again is likely influenced by age differences those with insurance need more care so they may end up with more out-of-pocket expenses and the difference is consistent across each of the types of out-of-pocket costs that are asked about including dental and vision where a third of insured and 3 in 10 uninsured residents have paid more than $500 in out-of-pocket costs with prescription medications where it's 22% and 17% mental health where it's 5 and 4 and then all other medical costs where a third of the insured population has paid more than $500 in out-of-pocket costs with the underinsured 8 in 10 of the underinsured population 18 to 64 with insurance has paid more than $500 in out-of-pocket costs in the last 12 months those who are not underinsured have paid more than $500 in out-of-pocket costs with the underinsured population the 3% in similar disparities across the individual categories we're looking at medical impacts of medical bills excuse me for the uninsured versus the insured population the only difference that is statistically significant is problems paying medical bills compared to 17% of the insured population this difference also has decreased over time but all other differences between these populations are not statistically different if we look at the trend there's really been significant strides trends in paying medical bills over time among the uninsured specifically over time since 2005 there's really been significant strides in reducing the proportion of these residents who have problems paying bills and who have been contacted by collection agencies where in 2005 40% of the uninsured said they have had problems paying medical bills and this year it was only 30% and in terms of being contacted by a collection agency that has reduced from 33% to 20% excuse me for the looking at the underinsured population those who are underinsured are more likely than those who are not underinsured to have had problems paying bills being contacted by a collection agency and to have used all or most of their savings to pay medical bills or to have had or unable to pay for basic necessities due to medical bills or even for this category both the underinsured and the not underinsured is small there are no statistical differences in having a person in the home receive a single medical bill for more than $500 that had to be paid out of pocket or having large credit card debt with the underinsured population there's not as much of a trend because we haven't been collecting that information as long but we still have seen significant improvements from 2014 to 2018 particularly in the area of problems paying medical bills and if you all have any questions for us great there's a lot of information throwing that at us in a very short period of time yes sorry fast talking but that was very good and there's some really good things to take away from this as far as our insured rate and I think that is something that we can be very proud of when you look at the underinsured a little bit more worried so my question is on the questions in the survey once someone responded that they had a high deductible policy was there a follow up question asking if there likewise was a savings account provided by their employer that would help them in that situation um I don't remember the specific order of the questions I can certainly we can certainly get that the there was the health savings account question but I don't know that it was specifically tied to the first question you mentioned so were the answers to the second question deducted from the answers to the first question and determining the underinsured rate I'm just trying to make some confidence so let me make sure that I understand what you're asking so if they have a health savings account were they not included in the underinsured question category so the question is yes they have a high deductible but if there are other resources made available to them by their employer do they then get deducted out of that account of underinsured I don't believe so no but I can confirm that but my understanding of the way it's calculated is no they are still included in that okay thank you questions from the board Tom thank you for this this is going to be definitely a document back to a number of times as it's actually very complex in a way so I had my questions kind of I had like six questions I think pretty lined up off your board and then I've tried to align them with the slide show I think I got it but we'll find out so I'm looking at slide four and I'm just wondering over time the catamount existed during this period as to the Vermont Health Connect plans and so in terms of where those treated similarly in this slide but I don't know the original surveys but was the half private insurance the other subsidies but it was that classified as private but it was catamount classified as private and the Vermont Health Connect ensured classified as private I can actually answer that for 2014 and before if that would be helpful that would be thank you VHAP was in previous surveys which would have been 2014 and before because the 2014 results were based on 2013 survey categorized as Medicaid because it was run by the Medicaid program catamount was categorized as private because the underlying insurance was a private insurance plan and it was administered by Blue Cross and MVP and Vermont Health Connect I would assume Vermont Health Connect plans would be private but I would defer to the Department of Health I'm just trying to think through I would have to check I believe they're private one was slide 13 I'm hoping and I just couldn't make the connection myself it's probably obvious but I couldn't find it I'm interested in the self-employed and the 7% and I'm that's 7% of what I'm interested in the number of self-employed people who are uninsured I mean you're looking for what the denominator is how many people are self-employed 7% times X gives you the number of I don't believe I don't have that with me I don't know off the top of my head how many people fall into that category unless you remember we can check next slide would be slide 19 and I had circled the lost the kind of striking the different increases from 21% to 34% for those lost eligibility not eligible for state health insurance and I'm wondering if what lost eligibility means could that mean lost eligibility because they pass through the 300% subsidy level and 400% subsidy level for my health connect policies or what some of it is up to the respondent to determine so it could have been that they moved across that threshold and no longer eligible there may be other eligibility requirements that they feel they no longer meet you know this whole these all these responses and we should have mentioned this is the respondents perception so it is possible the person is still meet the would still meet the requirements of the state health insurance program programs but for whatever reason they no longer feel that way and there were substantial eligibility changes in terms of the rules between 14 and 18 because of the implementation of the Affordable Care Act and the changes in Medicaid so that's probably a confounded issue there I'm just interested in those nuances when I look at this data I'm not sure there's enough specificity in the question to be able to answer that let's see going to slide 22 I'm just curious at the time I'm not sure there's enough specificity in the question to be able to answer that let's see going to slide 22 I'm just curious as to this under the short population ages 64 and under is this a measure of actual uninsurance that they that during the year they reached the thresholds that you have from the Commonwealth or is this a kind of projected uninsured policy never spent the deductible or the percentages that they come so it is based off of the respondents are asked what their deductible is and then they're asked about all their out-of-pocket expenses so from those responses those are collated and under insurance it's based on actual experience clarify because the Commonwealth definition defines under insurance is greater than 5% of household income if you're deductible is that amount regardless of whether or not you've used it there's two different tests one test is is your usage over a certain amount the other is just by definition deductible greater than 5% of your income yes thank you let me down the home stretch here I think it's slide 28 I was just interested to see that for example that visiting to the emergency room that the insured visited the emergency room proportionately more than those uninsured I guess I was just under the impression that it was the uninsured that used the emergency room a lot whereas those with insurance who have better healthcare avoid that this doesn't seem to affirm that all I know is what the result is I can't speak to why those differences might actually be there there's no statistical difference so the rate of visiting the emergency room is not different statistically there may be something related to perceptions around how much you might have to pay if you're uninsured that might keep them from seeking that care unless it's more of an emergency and finally I couldn't find the associated slide but on page 40 of the actual report is the calculation that there are 3,900 lives greater than 401% of poverty and so uninsured I think there's like 19,800 uninsured 3,900 lives in poverty but that's still kind of a small segment of the sample I'm wondering if you have a sense of what the margin might be around that 3,900 number no I don't have it now but we can pull that and let you know thank you any other questions Robin I don't have a question I just wanted to say as the person who foisted this survey onto you or got the legislature to do so thank you very much you did a fabulous job thank you and now I'm glad to know who's responsible have somebody else start your car Robin yeah I just wanted to comment on the underinsured if you look on slide 22 and this is kind of going to where I think Kevin's point was which is 40% of the people in private insurance are looked at as underinsured and I know on a separate slide I think there were I know they're not one for one but about I think 34 35% have HSA accounts and I'll give examples in the corporate world of saying someone could make $100,000 and they have a $5,000 high deductible plan so in that case they're hitting that 5% threshold yet the company's providing 4,000 in their HSA and they're really just out of pocket the $1,000 so it's just I mean it's just a point and certainly we've been talking with Diva about how to explore this population further you know I met with them last week to discuss additional analysis that we plan to do to try and understand the relationships here better and I think another shift looking at the decline in the people who are not insured anymore right which went down you know significantly and correlating a little unfortunately to them becoming probably underinsured but it's probably better than not having insurance at all but I mean it's like the shift there too there's a pretty close correlation to that number too I would agree I just have a quick question on slide 25 which was again I guess we're all intrigued by the underinsured this is by age so I was just wondering if you could unpack a little bit a third of Medicare recipients who fall into the category underinsured which of the triggers would have made it such that somebody on Medicare would be underinsured I don't remember whether we explored that by age specifically to look at what the specific reasons if I had to guess I would probably say it's more related to the out-of-pocket expenses but I would have to confirm that before committing to that yep no I agree just related to just this question I wonder if there's some way to get at that by looking at the previous numbers about where people have double insurance because my guess is if you don't get MEDS-UP which some people can't afford to that even the deductible could trigger it because you're you're mostly paying co-insurance though so maybe that's not true but I think that would be part of my question is I wonder how many you might not be able to figure this out in the survey but I wonder how many of that 32% have MEDS-UP are there questions or comments from the public and again address your questions or public or comment through us Deb yeah my question was the definition of under-insured from that one slide we used a common well definition but it didn't would be insurance premiums and yet a lot of my patients pay their own premiums which would put it seems to be taking more patients into that or the whole issue of public insurance and I'm wondering how that was addressed and some people aren't even sure how much they're spending or how much they're paying into their insurance premium by their employer I'm not sure if somebody asked me that question I didn't really answer and I'm thinking there's probably even more under-insured for yourself I'm sorry I'm not sure um um I don't really have a great answer it certainly could be more this has been part of our conversation with the folks at Diva and we'll continue to explore that and I would defer to them more we used the definition that had been used in the past and has been used by a fair number of other organizations but it does not include premiums great deal on this slide oh the delayed care yep it is possible and I would have to check that um we had had vision in the past and it just wasn't asked in this year it's possible that we changed the questions this year and it would be included again in the future it's a very good point yep yep this is just a snapshot in time yep Jessa did I said your hand up earlier um the question is whether subsidies are factored into it um I don't believe so but I will confirm um other comments or questions there's a lot of uh interest in this study I'm sure it was fascinating as you proceeded with this we look forward to some clarifications it's very useful information it's something that I think everyone has known for a long time that we've had a problem with under-insured this tends to confirm so thank you great thank you so we're going to switch gears again this discussion is going to be the ACL certification Melissa and Marissa you can come down change the slide deck and proceed okay thanks good afternoon for the record my name is Mike Barber I'm joined by Marissa Melamed and Melissa Miles and we're here today to talk to you about um our staff analysis of one care of Vermont's continued eligibility for certification our agenda is pretty simple for today we're going to start by going over the background providing some context for our review then we're going to summarize the findings from our review and present recommendations regarding one care's continued eligibility for certification we're going to focus on the new ACL certification requirements that the legislature enacted in 2018 and finally we're going to have some time for questions and discussion hopefully so getting into the background under 18VSA9382 an ACO has to obtain and maintain certification from the Green Mountain Care Board if it wants to receive payments from Medicaid or a commercial insurer under the all-payer ACO model or any other payment reform program or initiative the board was charged with adopting administrative rules that establish standards and processes for ACO certification and with ensuring that it only certifies ACOs that meet certain statutory requirements so the board did this in enacting Rule 5 Rule 5 sets out standards and processes for certifying ACOs as well as reviewing and approving their budgets as you know so I'm sure you remember but you provisionally certified one care on January 5th, 2018 fully certified them on March 21st, 2018 given the fact that we have a pretty in-depth annual budget review process for ACOs, Rule 5 does not require an ACO to apply for certification each year and undergo the kind of intense review we did in the earlier part of 2018 instead once an ACO is certified it has to submit a form to us each year verifying that it continues to meet the requirements of the statute and the rule and describing any material changes in the ACO that may affect its continued eligibility to be certified and ACO's certification remains valid while the board's review is pending if during the board's review it determines that an ACO is failing to meet one or more the certification requirements the board may require remedial action including placing the ACO on a corrective action plan this is the first year that we have undergone this kind of review process so we developed a form specifically for one care to complete it was tailored to the types of information that we got from them during the initial certification process after one care was certified the legislature added to the ACO certification requirements so in addition to asking one care kind of in the form what's changed in their operations we also asked them to answer questions that would help us understand whether they are complying with these new certification requirements just to quickly review our timeline the staff presented the 2019 certification eligibility verification form in June and a memo with the new ACO certification statutory criteria was presented in July together those the 2019 certification form which was voted on and adopted by the board on August 1st transmitted to one care and one care then submitted their responses sorry October 1st same time as the budget submission so we were reviewing those simultaneously with question and response period and today we are at our 2019 staff recommendation there will be a period of public comment from today through the 17th of January and there is a potential vote scheduled for the 23rd so the staff analysis and recommendations are outlined in a detailed memorandum to the board which is posted on our website under the ACO materials so first I'm going to give you a summary of all of our recommendations and then next Mike, Melissa and I will review the report for the recommendations as we provided in the memo this should be somewhat rougher than the memo there are additional details posted in that document and the memo is divided into three sections background and an overview of our recommendations and then discussion on the certification the new certification requirements and discussion on the annual eligibility verification so for an overview of our staff recommendation next I'll address the new certification requirements for the new requirements staff conclude that the those that were added to the statute are being met this will require a board vote since they're new we recommend the board vote to approve one care's continued eligibility for certification subject to reporting and monitoring requirements for those new requirements reporting and monitoring requirements in the discussion slides to follow and the new requirements are outlined here mental health access fair and equitable payments to minimize differentials among participating providers often referred to as pay parity and addressing childhood adversity in promoting resilience our second recommendation is regarding certification eligibility verification as Mike mentioned in his introduction for the initial certification one care is required to annually submit a form describing any material changes and our recommendation for those items are here first the board approved antitrust guidance after that initial certification that was approved in May of 2018 one care attested under oath in their October first certification submission that they're in compliance with the board's guidance no board action is required to continue certification for this item second one care submitted their certification form describing changes since the 2018 certification process highlights from their submission which are outlined again in more detail in the memo include review of leadership team organizational chart and board of manager roster changes review of the patient family advisory committee charter improved mechanisms for consumer inputs update to the participant appeals policy based on 2018 board review development of the 2020 network and several population health management and care coordination items after our reviews staff conclude there are no changes that affect one cares continued eligibility for certification and no board action is required to continue certification in addition just to note in their submission as part of regular monitoring and reporting one care agreed to submit the following documentation to support these items and support our ongoing monitoring of certification criteria and they will be reported as part of their quarterly reporting submission the board is required to vote on one cares compliance with new certification criteria that was added in 2018 so Mike and Melissa and I will review our analysis and recommendation for each of those so the first of the new criteria has to do with access to mental health and the board has to ensure that an ACO ensures equal access to appropriate mental health care that meets the Institute of medicines triple aims of quality access and affordability in a manner that is equivalent to other aspects of health care as part of an integrated holistic system of care we looked at five factors to determine whether one cares meeting this criteria we asked one care to describe its role versus the payers role in supporting access to mental health care we asked them about the financial incentives they provide to support access to quality mental health care we asked about their care coordination efforts we asked what other kinds of programs and initiatives they're engaged in on this issue and then finally we asked how they use data or facilitate the use of data in support of these goals and how they provide mental health and their quality measurement and clinical priorities and I'll go over briefly as I can essentially what they said and kind of our analysis of it so the first question as you can imagine one care explained that they are trying to integrate mental and physical health care services by providing resources tools and supports to enable integrated care teams from across the continuum to more easily identify people with mental health issues prioritize their needs and connect them to needed services as part of a shared care planning process and they stated that payers are responsible for designing benefit plans that facilitate access to mental health services and ensuring parity of coverage in network access regarding financial incentives one care described how they are making per member per month payments to designated agencies and other community providers to enhance their capacity to provide team based care coordination to high risk and very high risk individuals the preponderance of which preponderance of whom excuse me one care estimates have a mental health condition they also stated that they are planning to work with mental health providers in 2019 and 2020 to explore new payment models and delivery system reforms that will improve access to timely high quality mental health care as you know they will be developing a specialist payment pilot in 2019 and issuing community innovation grants and they will have to report to us on these programs later this year as part of the budget order however we recently received one cares or reviewed one cares request for proposals for the innovation fund and I just wanted to note that they are asking for proposals that could relate to this criteria of improving access to mental health specifically they are seeking proposals that will improve access to care, improve mental health and or substance use disorder prevention screening and or treatment advance care coordination for high risk individuals through innovative programs that address social determinants of health and that eliminate inequities in health with respect to care coordination one care talked about how care navigator allows providers to identify individuals with mental health diagnoses such as anxiety depression and bipolar disorder and has provided a common consent and re-disclosure process to help ensure that care team members subject to part two regulations can participate as active team members as you know part two regulations govern the confidentiality of substance use disorder data and have sometimes served as or at least been perceived to be a barrier to better care coordination for individuals with substance use disorders many of which also have co-occurring mental health conditions also we think that the comprehensive payment reform pilot turning into a program in 2019 may allow independent primary care practices to more effectively incorporate behavioral health and psychiatric care into their practices we just received a status update from one care on their 2018 pilot which is now posted on our website which describes among other things how the Thomas Chitenden Health Center was able to use increased financial resources that it received under the pilot to hire a psychiatric nurse practitioner two days per week and provide psychiatric services to patients with lacking health insurance coverage one care explained how that project began in March of 2018 and for the period of June through September the practice was able to increase access to a mental health professional by 80% we will be getting a final report later this year on the 2018 CPR pilot where we would expect to hear more about these kinds of clinical innovations that are being allowed or facilitated by the pilot with respect to other programs and initiatives one care mentioned how they have funded a full time mental health clinician through the Howard Center to support residents that to Burlington congregate housing locations where SASH has programs they mentioned that they have hosted a grand round on suicide prevention and are partnering with the blueprint for health to dedicate an all field team meeting to the suicide they noted that the diabetes prevention and management learning collaborative which is a joint effort between one care department of health blueprint for health SASH in a regional quality improvement organization is going to be focusing its final session this year on connections between diabetes and pre-diabetes and mental health and wellness and then on the last issue one care mentioned how they are working with Blue Cross Blue Shield of Vermont to share aggregate HSA level data on some key mental health and substance abuse quality measures with their network they mentioned that they have been working with Department of Vermont Health Access on a department wide process improvement plan to improve the initiation and engagement of substance abuse disorder treatment rate for Medicaid beneficiaries and then in terms of quality measurement they noted that a number of their quality measures relate to mental health and substance abuse and that one of their clinical priority areas for 2018 was related to mental health and we will want to make sure that they continue to incorporate mental health into their 2019 quality measures and clinical priorities obviously not only because of this certification requirement but also because it's important to meeting our performance targets under the all-payer ACO model so on this criteria based on our view we believe one care is working within its role as an ACO to ensure that its attributed patients have equal access to appropriate mental health care as part of an integrated holistic system of care as required by the statute we recommend that the board continue to monitor one care's performance on mental health related quality measures in its payer contracts and also review its 2019 quality improvement plan and clinical priorities to ensure that it is including mental health and prioritizing mental health in those areas we also recommend that one care be required to submit a report regarding its collaboration with the DA's on a part two common consent and re-disclosure process I think we'd like to understand more how that's working if they're seeing increased data under that and if so how that is being used to better serve patients with substance use disorder and mental health conditions so on the issue of payment parity the existing statute read the ACO has established appropriate mechanisms to receive and distribute payments to its participating health care providers and the language that was added is in a fair and equitable manner and to the extent that the ACO has the authority and ability to establish provider reimbursement rates the ACO shall minimize payment, shall minimize differentials in payment methodology among comparable participating providers across all practice settings as long as doing so is not inconsistent with the ACO's overall payment reform objectives so the board has been examining this issue since 2015 when the legislature first required us to report on it I last presented to you on this issue in August of 2017 after a stakeholder process and a memo that was submitted from the board to the health reform site committee examining this issue that was in October of 2017 and then this language is the result of discussions on the topic during the 2018 legislative session so to evaluate this criteria we looked at two factors to determine whether one care met the new requirements one the ACO's role versus the payers role in creating fair and equitable payments and minimizing payment differentials and two the ACO's steps to minimizing payment differentials so for number one one care has two mechanisms for making payments to providers one the all-inclusive population-based payment model we're participating providers waive fee-for-service and accept a lump sum perspective payment on behalf of attributive lives according to their contract with the payer the fund source is from the payer based on historic fee-for-service revenue paid in payer contracts second mechanism is direct supplemental payments made on top of usual fee-for-service or the AIPVP model these payments are also set in provider contracts and the fund source is budgeted by one care and includes hospital and payer contributions to one care these payments allow hospital and payer contributions to one care to be redistributed to independent and other community providers one care does have the ability to set the payment methodology and supplemental population-based payments one care does not have the ability to set the underlying fee schedule negotiated between payers and the providers second factor we looked at was the steps the ACO takes to minimize payment differentials in 2019 one care will make payments in three ways through fixed payments to hospitals capitated payments to independent primary care providers through the comprehensive payment reform program and population health management program payments the comprehensive payment reform program is the most direct program implemented by one care to help minimize payment differentials between hospital independent primary care providers it was piloted in 2018 with three organizations and is expanding in 2019 to nine organizations it's the three returning and six new the CPR program makes progress toward minimizing payment differentials by implementing a payment reform option for independent providers that is simpler and more predictable revenue stream and allows for clinical flexibility and innovation it invests in primary care it applies the same methodology to generate payment amounts across all providers by so each practice in the CPR program starts from the same base and then practice specific age, sex and risk adjustment is applied the payment methodology is designed to provide a transition to value base reimbursement models incentivize focus on population health and wellness and facilitate long-term participation in ACO programs and enable sustainable operations and meet the goals of the all-payer model so this is not inconsistent with health care reform and as Mike mentioned just a couple of days ago we received a status report on the CPR program the report does not include the final financial results for the 2018 pilot but the final results were requested in your recent budget order so those will be available so one care did report the following financial results on the CPR pilot program in June and presented this to the board in July so this is just a reminder the table is directly from their report the table shows per member per month for CPR participating practices modeled in three ways non one care Vermont model in that first column the standard one care Vermont model and then the comprehensive payment reform model compared with the model for hospital primary care practices in the fourth column the report does show favorable results for practices however as one care mentioned their presentation report as well this only includes two months of claims and our conclusion or our assessment is that there are favorable initial results from the pilot plus it's promising that there are additional practices that have joined in 2019 which is why the board requested that additional reporting in the 2019 budget so we believe that this reporting and the results that we've seen so far satisfy the criteria so just to summarize the certification recommendations for payment parity staff observe that one care is currently working within its role as an ACO to establish appropriate mechanisms to receive and distribute payments to its participating health care providers in a fair and equitable manner and to minimize payment differentials and again as part of the budget the board voted to require final reporting on the 2018 comprehensive payment reform pilot and interim reporting on the 2019 comprehensive payment reform program and we recommend that these budget conditions that you already voted on also satisfy monitoring for this certification requirement and this is the language that was voted on as part of the budget order so for the final area of new certification items that were granted by the legislature we looked at addressing childhood adversity and promoting resilience the ACO provides connections and incentives to existing community services for preventing and addressing the impact of childhood adversity the ACO collaborates on the development of quality outcome measurements for use by primary care providers who work with children and families and fosters collaboration among care coordinators community service providers and families for this statutory criteria we examined the connections between ACO providers who are addressing the impacts of adversity the collaboration on quality outcome measurements and then incentives for community service providers in looking at connections between ACO providers to address impacts of childhood adversity we asked one care to describe how they're working with stakeholders who are tasked in the existing legislation act 204 some of those stakeholders are listed here one care described that they have a population health strategy committee that directs the ACO's clinical initiatives in cooperation with state insurers and the community organizations they described that their board members on the population health strategy committee work with providers from across the continuum of care and these include primary care home health da's the Vermont food bank but it also includes the UVM health network chief of population health the Vermont commissioner of health and the Vermont child health improvement program leadership in addition they have a pediatric subcommittee that's comprised of academic and community pediatricians and family physicians in 2019 they stated that they would have increased focus on childhood adversity engaging with the agency of human services the blueprint for health Vermont care partners and their participant network to create cooperative interventions that are multifaceted and by example this year one care has met with the agency of human services and the department of children and family services staff to explore interventions for children who are and also in DCF custody they also referenced existing work that they're already performing to provide connections to providers who are addressing adversity which include their complex care coordination program their shared care plans and care navigator which permit medical and community agency personnel to target childhood trauma contributors one care also has extensive involvement in the community collaboratives and the regional clinical representative representative funding which we reviewed during the budget process the second area that we looked at was collaboration on quality outcome measurements so they stated that several in the one care network are exploring efforts to develop a childhood adversity screening tool that network providers could incorporate into their own electronic health records they gave the example that the today is testing a tool called the child and adolescent needs and strengths scoring tool secondly they are contracting with a data vendor to look at the health and prevention of the entire community and they're building a risk scoring algorithm with public and proprietary data to identify social determinants of health in that community which may place risk for adverse childhood experiences and this neighborhood or household stress risk score would be accessible in care navigator for their providers and would be combined with their Johns Hopkins risk grouper so it would be able they would look at be able to look at social needs as well as medical needs they've also stated that the use of this analytics will help them to identify cost and utilization drivers which may help justify additional services to address social determinants of health so they're beginning with a pediatric pilot and then they would expand it to adults and older adults based on those findings finally I would also note that they have two clinical priorities that could address social determinants of health as well one is a wellness priority to engage all patients in their annual wellness visits and also they have a food insecurity network being implemented across the network where networks are identifying how to increase access to food in their own communities so the third area that we looked at were incentives for community service providers one care highlighted that they are collaborating with the Vermont Department of Health to roll out the evidence-based program Dulce which stands for developmental understanding and legal collaboration for everyone so I did some research because I was curious about the evidence base of Dulce and it actually began as a randomized control trial in Boston in 2010 and then it was spread to six national sites in 2016 of which Lemoyle County was chosen as one of those sites and the model is that the Lemoyle County parent child center employs a specialist who is then embedded at their local federally qualified health center pediatric practice and that person works with families who are enrolled at the parent child center to support them in receiving enhanced social and medical services during their first six months of life and then in addition Vermont Legal Aid provides the legal assistance to the enrolled participants in the program so to continue this expansion for Vermont one will provide financial assistance for a statewide program coordinator to provide funding to continue research to test the program outcomes they're expanding to three new pediatric practices in 2019 who also have a rise Vermont campaign so this is our certification recommendation for one cares regarding their childhood adversity and resilience we observe that they're currently working within their role as an ACO to provide those connections and incentives to existing community services to collaborate on the development of quality outcome measurement and to foster collaborations among care coordination community service providers and families we would recommend that one care provide a timeline to address their 2019 plan which would include reporting back to us on the creation of new social determinants of health risk scoring how the screening tools are being incorporated into the electronic health records expansion and finally how one care will use their analytic capacities to identify the cost and utilization drivers to help justify additional resources for childhood trauma and any additional initiatives one care may be starting and now we'd like to open it up for discussion and public comment is over the 17th correct? yes so this is the next steps are that we have a public comment open period from 19 to 117 and then we are on the board meeting agenda for the 23rd to provide any public comment discussion and also a potential vote pending the conversation today through the public comment period any questions or comments from the board? I have just a couple of questions one in regard to payment parity charge here payment methodology amounts among the parable participating providers across all practice settings etc. I'm just wondering if and if so how does payer mix factor into this because different providers depending on who their payers are we know we have huge cost shift issues I don't expect the ACO to mitigate those but as much as possible because of the big movement forces out of the barn but in terms of the ACO is there any thought about that being a variable and figuring out how to make payments in a more equitable way? Well I would probably have to think that through a little and perhaps ask one care how the payer mix is factored into their methodology I don't know if I would just say that at least with the comprehensive payment reform pilot for any primary care kind of what they're trying to do is have a portion of the per member per month payment be a replacement for fee for service so what you're currently getting in fee for service we're going to replace that on a fixed basis and then add on kind of what you would get what you are expected to get with our additional program and then adds more money to that so to the extent they're replacing the fee for service I think that kind of builds in probably the mix you're talking about and on the hospital side which is the other payments they make you know the all inclusive population based payment that they're getting from Medicaid and from CMS is basically we expect this much money to be spent at hospitals for this population for the year and so it's again a replacement and then one care is taking a portion of that to redirect towards these other programs that they have so I don't know if that answers your question but I think that's how I think about pay or mix and what they're doing I guess I just finalize your question by asking if you can ask one care is pay or mix a factor in how they propose or how they do redistribute the additional payments from beyond to replacing the replicating the collective fee for service and then my other question was I think they're ready to answer you if you would like it I think they're ready to answer you if you would like it oh so a provider who is handicapped by a pay or mix that's heavily Medicaid for example that the across the board fixed payment doesn't seek to remedy that at all it's a more accurate so it's the rates that we set are not adjusted by payers I see so it is driven by attribution to a grant okay and the other thank you for that I didn't know you were here it's a question thank you Carolyn for noticing that and the other I have is having to do with the granularity if that's a word of these neighborhood or household stress risk scores I do see in the recommendations how these screening tools have been incorporated into the electronic health records but I guess I would like to know more as we come down toward a vote as to how granular the scoring system is because it seems that that these risk scores are maybe not the neighborhood score but the household score might be incorporated in people's electronic health records yet they are kind of being crafted by this Algorax Health consultant helping with this I just want to make sure that in terms of of the patient's consent or awareness of that that is being implemented and I don't know if Sarah you want to talk about that because we did chat with them about this so so that's my point is that this is a kind of a growth of healthcare and the social determinants health are valuable and I think we all can agree on that but now that it's being applied at a very micro level at the patient level I just want to make sure the patient understands why they're being asked these questions and once they get a risk score maybe the risk score explains it and I know that this is preliminary at this point in time maybe all the nuances of that question can't be answered today but it's something that I think is consideration as we move forward other questions or comments from the board if not I'll open it up to the public for any comments or questions, Dale Sarah do you want to take a crack at it tough one to measure other public comment or questions so again public comment the period through the 17th anyone can go to our website and share their comments with us and the 23rd correct we will be looking to take a vote so is there any old business to come before the board seeing none is there any new business to come before the board seeing none is there a motion to adjourn second it's been moved in second to adjourn all those in favor signify by saying hi hi any opposed thank you everyone drive safely