 We're about to get started and one of the first things that we will do is for those numbers that we don't have the names on the screen, we'll call off the last four digits so that we can meet the requirements of making sure that we have everyone logged in for the public record. So I'm going to start with 9997. I'm going to start with Amy Bodek from OneCare. Welcome, Amy. 6881. Rebecca, hi from Blue Cross. Welcome, Rebecca. 4191. Devin Green from Buzz. Hi, Devin. 96686. Sarah Teachout from Blue Cross. Welcome, Sarah. 6376. Mort Wilderman. Welcome, Mort. 9069. Vicki Loner. Hi, Vicki. 0283. Jonathan Kingston. Okay, 7438. 7438. 0538. Ginger Irish at OneCare. Welcome. Thank you. 0043. Becky Mondassi with DRM. Welcome, Becky. 5835. That's Abigail. Thanks, Abigail. 4485. Hey, this is Nolan from JFO. Welcome, Nolan. 1970. It's Janine here at the office. Thanks. 3000. Feeling that's me. Then call us UVM Medical Center. I'm on my desk phone. Okay, great. Thank you. Thank you. 3212. Hi, it's Kathy Mahoney from the advisory committee. Welcome, Kathy. 1460. Yes, hi. This is Jessica Barnard with the Vermont Medical Society. Welcome, Jessica. 5817. This is Jill Sotoff-Garron with the Vermont Medical Society. Hi, Kevin. Hey, Jill. 5572. This is Tom Darenthal in Burlington. Hi, Tom. 0686. This is Roger Arnold in Norwich, Vermont. Okay, I believe that everyone else I have a name popping up for. Is there any numbers that I have missed, Abigail, that you do not have a name on? No, but I think asking if we missed anyone, they can speak up just because I see people were added as we went along. I haven't gone on yet. This is Maggie Lems from Leonine Public Affairs. Thank you, Maggie. Anyone else? And Walter is here, too. Okay. Who's that? Welcome. B.T. Jickling, B.T. Digger. Hi, Katie. Anybody else? If not, the first side. Go ahead. Sorry, Kylie Kuiper, Office of the Healthcare Advocate. Hey, Kylie. Okay, with that, we'll go to the Executive Director's Report. Thank you, Mr. Chair. Welcome, everybody, to our board meeting today. I have a scheduling update for next week. We have added a couple of meetings. Actually, one extra meeting to the schedule for April. We're going to be meeting on April 29th, next Wednesday, starting at 10 a.m. We'll have a board meeting to discuss the Northwestern Medical Center 2020 budget amendment request. And that's a potential vote. And then we'll be coming back virtually to meet at 1 p.m. Next Wednesday. And we're going to hear from our health insurers in the state on their COVID-19 response. I have heard and confirmed with Blue Cross Blue Shield as well as MVP. We're still waiting on confirmation from SIGNA. And I've also heard from Commissioner Pichek that he will be presenting to us on their response and some of the updated rules that they've been working really hard on. So it should be a very good meeting. That is all I have to report out today. Any questions? Hearing none. Thank you, Susan. You're welcome. The next item on the agenda are the minutes of Wednesday, April 8th. Is there a motion? So moved. Second. It's been moved and seconded to approve the minutes of Wednesday, April 8th. Without any additions, deletions or corrections? Is there any discussion? Hearing none. Council Barber, if you could call the roll. Member Lunge. Yes. Member Holmes. Yes. Member Pelham. Yes. Member Yusufard. Yes. Mr. Chairman. Yes. So with that, we're going to go to the One Care Vermont 2020 update. And Elena, are you going to do any intro or should I go right to Vicki? I hadn't planned on it, but I think we could just, you know, tee it up with we. This is in response to, you know, board concerns around hospital solvency, as well as the request for operational release from One Care. And I think this is a check in to understand the work that's been done at One Care and to understand their role in the response to COVID. So I'll leave it at that. And Vicki, thank you for joining us. Welcome, Vicki. Good afternoon. Thank you, everybody. This is a sound check. Can you hear me already? I can definitely hear you. I can't see you, but you might just be on the phone. I don't know. No, I'm actually on as a guest. What I'm going to do is try to present my screen. So that you can see the PowerPoint. So let me know if I am successful in those endeavors. Well, I can at least see you now. There we go. That's good. There's the screen. Oh, we had it for a second. There we go. Okay. I'm getting to become a professional at this. So thanks to Abigail, who helped me prior to our time here together to make sure that this was successful. So it seems like it was. So, and it's great. For those who are following on the phone, I want to say that I'm starting on slide two. On the phone, I want to say that I'm starting on slide 2 of the presentation labeled one cares response to the COVID pandemic. And hopefully those numbers of the board can still see it and saying, all right, we can. Great, I would say that overall have a cured approach to be able to support the delivery system and Ramon during the pandemic. And the way that I look at it is, you know, of course, our greatest impacts come where we are partnering with either the federal state or payers or the providers who are delivering some of the frontline care or over monsters. We had all of our having said that take in many independent actions, which I'll be happy to share with you as we move through this presentation to assure really that stability and predictability and payment funds as well as to provide immediate cash flow release to hospitals, primary care practitioners, designated agencies. Home health and area agencies on aging. So that will be, I'll talk to you about that a little bit more during the presentation. And then of course, as you move down a lot of the actions that we've initiated really do require that partnership with the federal state and payers. To reduce administrative burden, we've talked a lot and we've had the, the network of providers really change the way that health care is delivered through many of the telehealth that has been approved at both the state and federal level. So, thank you to our state partners and our insurance company who have provided some parity for those visits. And then, I think a couple of weeks back, I lose track of time, really trying to make sure that there's no financial penalties related to being part of these health care reform efforts. And again, we'll talk more about that later on in the presentation. And then I'd like to kind of reveal or to provide you some more information on a new care coordination tool that really helps to identify those for monitors who are most at risk during COVID-19 pandemic in ways that we can support them and their needs as well as to make sure that the system has enough capacity to be able to care for them. So, could I just ask a process check? Would you like me to move through the presentation and then take questions at the end, Chair Rohn? Yeah. And since I can't see other board members, if they do have a question that they would like to get clarified immediately, they could just cut in. They'll have to do it themselves as I won't be able to recognize them, but otherwise we'll hold everything till the end. Okay. Perfect. So, I am moving my way to slide 3 labeled Board of Manager's Commitment to Supporting Providers of Care. Really, these are the activities that OneCare has been working on since the beginning of COVID-19 to assure that our providers have cash flow to be able to support them on the front lines. Both with care delivery and to make sure that they're not concerned about their financial solvency when it comes to the services that they're delivering under the ACL model. And list of order, and I'm not going to go into these in too much detail, but what we've heard is those fixed payments that are being received through both the Medicaid and Medicare program right now are really vital to the practitioners because they are predictable despite the revenues going down at all the hospitals. I think the only wish at this point in time would be that that was a higher percentage of their overall revenues that they wouldn't have to be relying so much on fee-for-service and the normal payment system. We are working or started a pilot program at Bennington at Southwestern Medical Center with Blue Cross Blue Shield starting in April to look at a fixed payment for the qualified health plan business. So, we'll be happy to provide some updates in May as to how that process is moving along. And Blue Cross Blue Shield has offered it up to any other hospital that is participating to be able to support them. I would just ask if everybody could mute their minds because we're getting some audio that's not from Vicki. Thank you so much. One of the earliest changes that we made was there was set to go into effect on April 1st a change in our Care Coordination Payment Structure, which would move from a system that paid based on a capacity payment to more of a performance-based payment. And given that networks need to really be agile and make sure that there was access to those with COVID, we felt like that was premature to change those payments at this time. So that payment change has been delayed until September 1 of this year. I think I talked last time we were here about offering those grantees the ability to take a pause on the innovation grants for the year if they needed to without repercussions or loss of income as a result of this. We have at our last board meeting for the Comprehensive Primary Care Reform Pilot. And remember that's for independent primary care practitioners that are in all payer programs for which one care Vermont has a contract. And they receive a fixed payment for the number of grantees that they have on their panel that are attributed. We did have a component of that. That was, yes. Is somebody talking to me or just somebody hasn't muted their line? I think somebody muted their line. Unless, Tom, you didn't have a question, did you? That wasn't you, was it? I think it was just someone that hadn't muted their line, Vicki. Okay. Great. Thank you. So we had two quality measures that providers in the program could receive additional incentive or a reduction in their overall payment based on their performance in these particular measures. We do not believe that this is a time to penalize providers who are working so hard on the front line. And so we took away any sort of financial penalties, the results of those measures. We are still asking providers to report how they are doing and those measures and still working on process improvement flows. If there has been a significant decline in those measures and really digging in to see what was the root cause of the decline, was it because they needed to mobilize to support COVID or were there other circumstances occurring? I'll show you on slide four. We have heard and done much outreach to our primary care, both independent, FQHCs, as well as our hospital partners to assess if we were able to accelerate some cash flow to them. Would that be helpful for the months of April and May? And we overall received a very positive response that that would be something that would be helpful as they work their way through recovery. And so I'll show you some of those accounting mechanisms on the next page. We also did, and thank you to the Green Mountain Care Board for your swift action on that, have a vote to return the Medicare portion of the value basin census fund back to hospitals. And we have stopped collection of funding for the rest of the year for them as well. So that provided a little over a million dollars in relief to the hospitals for that. We are, because we are working with payers, and I think this was part of our recommendations to CMMI to have this year be a reporting year only on quality. So again, not to have any financial penalties tied to any changes in those quality metrics this year. We had prepared a policy change internally that if this was granted across all payers, we would start to release that funding out to the network in accordance with our policy on a monthly basis. So again, that would be a mechanism to enhance cash flow for them. And then we'll show you later on an application that was developed rather swiftly and is continuously being enhanced to really support those verminers who might be most vulnerable during this time. So I'm just taking a pause to see if it seems reasonable to continue on, or if there's any quick question. I'll throw out a quick question, Vicki. You talked about the feedback from everybody about how important the fixed perspective payments were. Have you had any inquiries from providers about possibly having a mid-year process for allowing others to join? We have not had that question posed to us. I think it would be challenging with the payer contracts to bring in new lives in the middle of the year. But I will say that in talking with Blue Cross Blue Shield, they were very willing to extend this fixed payment type scenario to those hospitals that were not currently participating in one care. That was something that they thought would be supportive of them. Kevin, may I just build on that question with a quick one? Absolutely, Jess. Go ahead. Thank you. So Vicki, I'm just wondering, I noticed that you are piloting this fixed payment with the Blue Cross Blue Shield QHP at Southwestern only, but that Blue Cross offered it to other hospitals. And I'm wondering if you could just speak to why other hospitals, given the appreciation for the predictability of fixed payments, didn't jump on that opportunity? Yes, a great question, Jess. In talking with the hospitals, this is an operational lift for them right now. And we have been working with Bennington for quite some time to make sure that their operations could support this. And they wanted to give this some time to work through Bennington to make sure that if there were any bugs per se that those were fixed. And that if we were to be able to identify any other areas of efficiencies that we would be able to do that over the next month or so and then make some reevaluation. It was just really too challenging during the time for them to be able to quickly move to that type of payment. Because of the operational complexities. Any other questions from the board? I have a quick one. Vicki, you had mentioned you'd given providers who got the innovation grants the opportunity for a pause. I was wondering what the take up on that was. So far, Robin, and I can get back to you if there's any change. But the last time I checked most of the grantees wanted to continue moving forward. But they appreciated the opportunity at any point in time to say that perhaps a pause would be necessary. And so we just continue to touch base with our network and our contractors to make sure that they're still in a comfortable place with moving those programs forward. Thank you. I think everybody can appreciate that every day feels a little bit different than every challenge. Every day brings a new challenge. So it's just important that we keep closer communication with our network than we ever had previously. So moving on to slide four that says financial support to providers. We talked about continuing to make those fixed payments to hospitals and comprehensive payment reform for the independent practitioners so that despite their lower billings, they can continue to receive the cash flow that they normally had pre-pandemic. And I believe that this Screamant Care Board and the signers understand that it's really important that we continue to advocate for the Medicare payment at least for this to be unreconciled at the end of the year so that it be a true fixed payment as it is with a Medicaid program because that will really provide an additional level of support for providers post-pandemic and to make sure that they can indeed make a successful recovery. We talked about the $1.1 million and indeed that is being returned to the network providers. We are preparing to make an advance of our May and June population health payments and that is the $3.25 that we pay to primary care and the care coordination payments that are the recipients of that are primary care designated agencies, home health and area agencies on aging. The preliminary estimates of that advance is roughly $2.4 million. That is an advance and we will be working with the provider's route the year things start to stabilize to reconcile those payments so just to be clear of the intent of that. But in talking with providers the preponderance felt like the needed cash infusion right now was something that would help them as they prepare. And then we talked about the delay in the care coordination program payment model. We also made a decision our comprehensive payment reform provider the independence to allow that delay to occur for them as well. I will say in the care coordination delay from moving from an infrastructure payment to a performance payment or a capacity to a performance payment we did identify that there were less than a dozen primary care providers that were exceeding the level of performance and participation than what would have been accounted for in the capacity payments. And so we have reached out to those practices and we will be providing them the delta between what the capacity payment would have been and the level of engagement that they're actively making right now. So I just wanted to clarify that. That has been done. May I move on to slide type? Yes. This is I've talked a lot about this in my reports to both the House and Senate committees on healthcare administration. This falls into those tiers of activities that really do require a partnership between one care and our federal state and the signers of the all payer model and have the ability for the greatest impact both this year and as we move through next year and to the completion of the all payer model agreement perhaps in 2022 depending on how activities flow. We've been very active at the national level partnering with the national accountable care organizations to make sure that those providers who have been leaders in healthcare reform efforts at the federal level because that is the way that the federal government is moving are not penalized in any way for their activity and we are seeing some movement in that direction but nothing has been affirmative in terms of how they'll be looking at shared savings or quality measures for this year or next year. So we're still waiting on those type of activities. We have also been working rather tightly with the state administration officials as this committee knows there were some crucial admissions in the stimulus payment calculations in that the all inclusive population based payment i.e. shadow claims were not included in that calculation to determine what the hospitals and independent practices would receive who were under that type of arrangement and so we do know that a letter was sent by the administration and by a few members of our delegation to HHS who is administering the stimulus program and that they have reached out to CMMI to validate our findings and we as a couple hours ago we're still waiting to see what the timeline is for making sure that that data is included and recalculated and if that is indeed their intention and then locally we have been working very closely with you and the other signers to make sure that for the Medicaid or Medicare all-payer model agreement that we're looking at those all inclusive population based payments we would like them to be truly fixed so that the hospitals and independent primary practitioners who are receiving those payments can rely on them throughout the year making sure that clinicians are held harmless from any financial penalties so again we're not stopping quality related activities those will continue on throughout the year having high quality care is something that's very important to us and we know that providers right now are working very hard to try to support access for those who are suffering from the effects of COVID so we are saying let's make sure that this year we're thinking about it as a reporting year only we'll continue to do our diligence but we don't want any financial penalties to occur. The other big portion of it too is making sure that the hospital systems that are taking financial risks are held harmless for any portion of the Medicare payment that has been paid to advance the shared savings for the blueprint for health and supports and services at home when those discussions do occur and I think it's always important to look at with this waiver are there other additional funding opportunities that could be provided to those providers who have really been leaders and the L-Pair model agreement and as I understand it that letter has not yet gone out but is expected to go out sometimes within the week so that'll be very important to have those conversations and continue moving that forward. At the state and payer level it's a similar theme and that really we're looking to make sure that the hospitals that are accountable for any kind of financial risk are not harmed by the impact of COVID on the program and that there's no financial penalties for any of the network that's primary care the designated mental health agencies the home health for the quality reporting and then we're always talking to payers to assess is there further opportunity to expand the fixed payments such as with Blue Cross Blue Shield and we continue to have conversations with our network on a monthly basis and the CFOs very frequently to assess if it would be helpful if we took some of those fixed payments and spread them out throughout the month so that they had a constant infusion of cash flow so we're keeping close tabs with them on that and also I think it shouldn't be taken for granted that making sure that there's no additional administrative burden in the form of prior authorization protect against that and so that's been activities that we've been working on with the payers and state Medicaid offices and they have been excellent partners in all of this and I really commend their efforts and make me sure that the health firm honors really take precedence so now I'm going to move us along to slide seven somebody needs to put themselves on mute one of the applications that we were able to develop rather quickly as we were hearing concern that there might be individuals who were at high risk because either of their age or their frailty or multiple chronic conditions that during this time of social distancing and social isolation might not be seeking care from the healthcare system so what we did is using the data that we have at one care and criteria from the World Health Organization the CDC and Johns Hopkins as we deliver we developed an application that was able to identify those individuals who were at greatest risk during the COVID pandemic and really the goals were to make sure that patients are safe and to be able to identify needs that they might be having during this time that they haven't reached out to their healthcare practitioners to talk about because of their concern of inundating the healthcare system right now when I sent you this slide we had 26 organizations who are using the application were up to 30 organizations as of today that are using it the primary care providers that are using this application and taking the list from it have reported back that they're finding it very helpful in identifying individuals who perhaps weren't getting their prescriptions filled or that they weren't able to get food because they were scared to go to their local grocery store so helping to connect them with services in their communities to make sure that they had the food in the medication that they needed to keep them healthy with some of the anecdotal findings that we're seeing we're also adding to this application some food insecurity and social isolation questions as well and we've also heard from our network that they would really like to continue utilizing this application into the recovery phase to make sure that people are being connected with their primary care we've developed some nice scriptings for the care coordinators to use it's called a care and concern script to identify what needs they might have and then perhaps based on that assessment they get them connected in with a telephone or telemedicine visit with their primary care perhaps their mental health clinician based on the findings that that the care coordinator receives and then moving to slide eight of the presentation labeled providers working together to create a better healthcare future. I thought that this picture was really looking forward to the bright future that Vermonters will have post pandemic and really thinking about how we continue to work towards transitioning to a full value-based system that indeed we found that during this period of time that the dependency on fee for services when you know certain services have to be shut down to make sure that we keep people healthy and well is is not a good long-term plan for for us or anybody and that vermont has been real leaders in this we're seeing through this process really a more consistent care model so thinking about the work we're doing in that care coordination arena and some of the outcomes findings that we're seeing based on this and the quality measures is really important when you have providers and working together as a true system of care to really improve the health of Vermonters and we talked about those fixed payments really being vital to the point in time when the care delivery really needs to shift the way that it's delivering care if you even think about something as I guess I'll call it simple but I know it wasn't simple we've worked really hard with the association leaders to make sure that providers were able to make those telephone consultations and receive reimbursement for those consultations in order to make sure their financial solvency was viable moving forward and if we were truly under a fixed payment system for hospitals and primary care those providers would have been able to be more agile and fluid because they would have been receiving those fixed payments so regardless of whether or not a code was in place for those services they would be able to move quickly to provide those services to members without having to take that extra step of making sure that there were dollars and codes assigned to those particular services so that concludes my presentation and I will keep it up in case there's questions and I need to go back to certain slides. Super thank you Vicki you touched on it briefly but what are you hearing from providers on the telehealth issues I was telling the board at our admin check-in I believe it was Monday that my granddaughter had a tick and gorged at her hairline and when my son called the pediatrician they facetimed it and he examined her using the phone and wrote a script for medicine based on the the telehealth are you seeing a lot more takeoff of that? Yeah we're absolutely seeing a lot more uptake of the telehealth I would say anecdotally what I'm hearing is that more people are leveraging the telephone consultation and not so much the video aspects of it I think if somebody has commercial insurance or a Medicaid that doesn't present a challenge in terms of the reimbursement for it but with Medicare that rate is significantly lower if it doesn't have a video component to it so we're in the process actually of looking at the claims that are coming through seeing where the greatest uptick is and we met when we met as a board this very issue of telehealth came up or telemedicine and really the what I'm hearing from the health care providers is even post COVID and through the recovery this is an amazing tool to be able to provide care and that patients experiences are positive during this point in time so we're going to be assembling providers throughout the state thanks to Tom B from Bennington who had this idea to be able to get everybody together to share best practices on how things are working right now with telehealth and then looking at what we might need in the future to be able to continue this mode of care delivery and for what populations so it it's really interesting in how such a short period of time we've we've changed from some of those traditional face-to-face visits to these telehealth visits out of necessity yeah yeah yeah absolutely okay questions from the board hi Kevin it's Tom I have a couple go ahead Tom um just wondering in terms of your care coordination new app you said that there were 30 organizations that seem to be active on it I'm just wondering if you have any sense of how many people are being served by it so um we don't have those counts yet so recall that people who are using this application may or may not be using care navigator and that is the place where we've been able to really provide the means of account also if they're not doing available code as a result of this we won't be able to see if you know a service has been associated with it from a clinician so we won't have absolute counts but we certainly do have the ability through care navigator to be able to assess how many people are engaging in some care coordination activities as long as they're using the app good thank you um I mean this could be that I've misunderstood what I've heard but you know in terms of the provider payment system funds from the federal government you know those as I understand it are based on a Medicare distribution of that of the provider over the entire national distribution Medicare funds and I've heard some say that pediatricians because they don't do a lot of Medicare business are kind of like left outside the loop for those provider payment distributions does that ring any bells for you I have not heard that comment I know that there will be multiple ways of funding and one as I've heard will be more towards the Medicaid populations and so perhaps that's where some of the pediatric practices will get picked up because there'll be greater emphasis there but I have not heard that would make sense so and then just in terms of your view of your own organization we spent and thank you for that a lot of time kind of looking you know over the fence at your provider network and payer network but I guess I would like to ask what is is you know you know we have risk quarters for hospitals what are the risks before the ACO for your organization that you worry about the most I think the risk for the ACO in general are that providers won't be able to continue their participation in these healthcare reform efforts because of perhaps some of the penalties that might apply perhaps because of the pressures they have on them financially that if you recall the hospitals are a big contributor to the population based payments that go out to all the other healthcare providers and as they don't have you know a healthy income coming and they won't be able to participate in some of those programs moving forward or pay for some of those programs and we have some delivery system reform payments coming in but certainly not to the degree in which the hospitals have participated in those funding programs. Just one more so do you see any window of opportunity to I mean that's a risk that you've just defined you see any windows of opportunity in terms of federal funds this array of federal funds that are at play I notice for example that the small state minimum but not going to get 1.25 billion dollars which is a lot of money it's about 78 percent of our general fund spending and my understanding is in the bill that's before the house today they are expanding the ability of states to use that money giving states more discretion and before it was just limited to reimburse COVID expenses and it's a and I don't know what the language is yet but do you do you have any insight into any of these federal streams that that you folks might help hospitals leverage beyond what they can leverage independently. That's a great question most of our efforts have been focused towards helping the healthcare system really leverage the funding that's available to them in those first couple challenges that are going out for Medicare and Medicaid but I'd like to give your question some more thought because it's a really good one that there might be some opportunities that we as the CEO and the entire system of care could be supporting Vermont drawing down some of those funding opportunities. So I noticed someone sent me an email from our state budget office as a you know to the National Association of Budget Commissioners and you know because there are 24 states that are small state minimums that's quite a coalition that can be put together in terms of of helping define what's eligible and what's not when you have 24 states you know that that's quite a coalition across the country and I just you know I I just you know I know it's a fast-moving environment and I don't envy you but you know it's that's all I have to say about it's a lot of money a lot of opportunity the flexibility is growing rather than diminishing and I'm you know I'm just hopeful that you know in the scheme of things the bulls in in your advisor are probably quite small relative to the ones out there in the field and I'll leave it that. Yeah I think that's absolutely a fair statement that's why much of our efforts have really been geared towards doing everything that's within our control and advocating for providers to receive funding that they need to not only continue and make it through COVID but to be able to participate both once we we move to a brighter future. Thank you Vicki. Thank you Tom. Robin do you have questions? I asked most of my questions as I went along or someone else already has so I think I'm good. Thank you Robin. Maureen do you have any questions? Nope I'm good as well thank you. Okay Jess do you have any questions? I do I just have two I think one Vicki the board approved the return of the Medicare portion of VBIF to hospitals and I'm wondering if you were able to return the Medicaid portion of VBIF to hospitals if I recall that was a significant amount. It is a significant amount we had put in a verbal and written request we have not received the response yet so we have not been able to return that funding. Okay how much was that amount? I think I can double check I think it's close to four million in Medicaid okay and that's why we had prepared the policy if Medicaid did allow for it to be able to send that money out to hospital primary care designated agencies on a monthly basis so that way the whole system is cared for with that valuation fund fund. Okay thank you and my second question revolves a little bit around some of the programming for the 2020 budget. I'm thinking about programs like Rise Vermont and Dulce which require social connection and in-person you know engagement walks you know in the town together and house home visits you know for new families and so my recollection is that's you know close to two million dollars that was in your budget and I'm just wondering if you've thought about that in this current social distancing stay-at-home world that we're in. Yeah I think it's becoming more and more reality and at our board meeting in April we really did have some active discussions about what our focus needs to be and where we need to look to make sure that we continue funding and places that we might need to scale back and to your earlier great points Rise Vermont is one that does require a lot of social connection and so we can keep that going at a minimum level but we don't have an intention to scale that further this year and so I think you'll see that as a change when we come back in May. Okay and actually this is just a my my last question and I'm not sure that you have the answer to it it's not specific to your budget or your and maybe beyond your scope of knowledge but I'm just sort of thinking about is there a possibility that because we're seeing fewer non-covid sick visits in primary care offices people staying at home not having work injuries not you know getting sick from flus and things like that because they're at home we're hearing about fewer visits and that's affecting obviously the revenue for a lot of the independent and primary care practices now that we have telemedicine ramping up in terms of reimbursements I'm just wondering is it possible that we could be seeing more provider outreach in ways that would actually see some improvement in some of our quality metrics like providers possibly having time where they didn't before to you know sort of along the lines of your care coordination prioritization app but even beyond that just reaching out to their panel that they had didn't have time for before in ways that might actually improve some of our quality measures just a big big 40 000 foot question but yeah I think it's a great question and it will be interesting to see you know as we track this COVID application and those visits that kind of start off as a care and concern kind of non-billable from a care coordinator and if we can then make an assessment of how many of those patients actually made it a billable telehealth code at the end will be interesting to see I know that our Chief Medical Officer Dr. Ward actually you know reached out to some of his patients using this application and has found it quite helpful right to be able to have that connections and ways to individuals that he might not have had previously so I think there's a lot yeah okay thank you welcome before I turn it over to the public in a minute for comments or questions I'm going to ask staff through Elena if they have any questions and while you're preparing to answer that Elena I had one final question for you Vicki and that is you talked about the 1.1 million in direct relief to the hospitals and you talked about the 2.4 million in advanced payments can you tell us what period of time those advanced payments cover they do cover the months of May and June so we're making a payment well actually they're April May and June so three months okay are you giving any consideration depending on how this plays out doing something beyond the June timetable I think that's going to have many factors associated with it in terms of our revenues coming in through delivery system reform we're still having discussions with the state about that and whether or not we're able to continue to make those types of advanced payments okay so Elena do you have any questions I think the board covered most of my questions I think you know we'll be interested to see where where May lands where it brings us to and they think we'll have more questions at that time about more precise relationships between funding and and and the response okay so I'm going to open it up to the public for public comment would anyone from the public wish to make a comment go ahead more um this is all anecdotal but I've been speaking to lots of physicians and some patients as well about this telehealth experience and I think we can anticipate that healthcare will never be the same when this all settles down because there is incredible advantage to not having to go to a physician's office you we forget that in the early 20th century and right until the last half of it anyway physicians and nurses visited families homes and it was only for the convenience of physicians that it all got switched around to where patients had to come into physicians offices really physicians used to drive around now they don't so all of a sudden consumers don't have to go to physicians offices and as a physician I can tell you that the physical examination is but a small part a very small part of what happens in a what happens in a healthcare encounter except for specific things that take measurements that cannot be accomplished remotely a lot of it is simply listening and eliciting symptoms and I think that the insurers are going to have to come around and see that this is possibly much better for patients and actually probably better for physicians and providers of healthcare and their lifestyles as well when this all settles up provided that payment is possible and quality can be assessed thank you more I think that is something we're hearing from everyone I don't I don't think necessarily are you expecting a comment back from vicki or no just to say tell vicki she did a great job okay thanks more thank you I think a comment in response to mort's comment certainly robin um I I think that thanks more for your comment it's great to hear the anecdotal report on how that's going one concern that I had in terms of the the telehealth language that the legislature passed is that it is time limited so if we were to come out of the state of emergency uh but um but prior to the first of the year there it could be a gap uh there between the authority to continue telehealth so I just wanted to mention that because obviously our legislature is still in session and so folks may want to raise that issue if they are also concerned about that thank you robin very good point other members of the public hi hi i heard mike fisher go ahead uh good afternoon kevin on the board and vicki um I don't know whether vicki would have a perspective on this um I totally understand uh it makes sense why the prospective payments have been so valuable during this time when uh there's a great deal of non-covid care that has not been being delivered um my question is and of course we don't know what happens next when we move past the crisis stage of this um but if in the next phase there is a wave of pent-up demand uh coming out our provider community um how and there's a need a potential need to ramp up some um capacity to manage that how is that going to I wonder if you have a perspective on how the finances of that will work I think it's a great question and one that we really don't know the answer to right now I think of course you'll see that um people will need to be receiving their elective surgeries and procedures I don't know what the timeline for doing that and whether not you see that immediately within the first couple of months or this is going to be in overtime I also think that providers right now are trying to think about when we come out of this and start moving into recovery is there another phase or resurgence that we need to be planning for until such time that we actually have a vaccine so I think that's another very unknown variable and the equation right now that we have to plan for in our recovery period which from what I'm hearing could be anywhere from 12 days 18 months thanks okay other members of the public chair mullen this is kathy falton I'd like to share share some information go ahead kathy hi everybody and I I just want to um reinforce Vicki's assertion that telehealth has exploded um we vpqhc the vermont program for quality and health care has been very aggressively partnering with the northeast telehealth resource center to provide twice weekly office hours we had an exceptional session this morning going into the details of some of the coding and reimbursement challenges that were that were faced with across federal state commercial programs but to kind of answer some of the discussion both Dr. Wasserman and Jessica as you've shared tomorrow morning at eight o'clock Dr. Norman Ward from One Care Vermont is hosting a conversation um and you know facilitating a discussion on the future of telehealth for vermont providers um everyone within earshot of of this message you're welcome to join us you can go onto the vpqhc website to get the registration information but um we will be addressing and looking to exactly what you described Dr. Wasserman and how we continue to support the preparation going forward because um you know we've all heard on in several channels this is in this isn't just the first time this will lead us into the new normal and we can expect more and um preparation and management of very um things like pent up demand and what would be the quote-unquote normal um care delivery uh how this has to be modified and expanded going forward so we welcome all of your um engagement and suggestions and continue to support the effort on a statewide basis and we're happy to answer any questions anytime thank you Kathy other members of the public hi yeah sure this is jessa with the vermont medical society and i just want to thank vicky for all the work One Care is doing and echo what she stated about practices really looking to predictable payments going forward and we're hearing particularly at the national level from family physicians a real interest in moving towards more capitated payment systems and so we are looking forward to working with with One Care on that with the primary care practices and um seeing what the future can bring and what we can learn from this experience also just to some kind of question we have heard that concern about the medicare advanced payments being they're distributed based on your percent of medicare fee-for-service payment so it has favored those types of practitioners who have a high percent of medicare versus medicaid patients but we are also um as vicky mentioned hearing that future hopefully future waves of funding will address that and um go to pediatricians and others that have a lower medicare number thank you jessa thank you thank you can i hear someone else trying to get in go ahead yeah this is this is anmarie christensen representative on the health care committee i took note of the telehealth um expiring you know january first and knowing the legislature we're just going to take bills up that are important and covid related but somehow or other you should probably you know hop on to that whoever is in charge gets some information to the both health care senate and house um the other part is i personally had a great experience with telehealth it's it's just like mind-changing you know with talking to the doctor on the phone but also is i don't think when you're uh emailing your doctors through your electronic medical record i don't know if that is covered um it may be in the bill that we pass but i'm not quite sure but that's also been very helpful um so anyway these are things to think about of getting some proposal ready that could go in on the short time frame while we are in there voting electronically would you like us to send something to you or to gen carby or how would you like that done representative christensen i would think i would send it to the chairs of both committees um the senate and the house um bill and jenny alliance so robin can you uh volunteer to take on that task sure okay thank you you know i think back and uh i remember being a sponsor when i was in the legislature on one of the first uh what we were calling telemedicine at the time and and uh people thought that uh it would never go anywhere and now you look at uh how it's uh expanding so rapidly in this uh unprecedented time and you know telehealth um has some great use as we try to face uh workforce shortages uh especially in rural areas in the united states so um i'm glad that so far things seem to be working very well other members of the public yeah yeah hi erina from the developer hi um so i just and i don't know uh mr chair if this is a question for uh the board staff or for vicki loner but i'm just trying to get a handle on what percent of um one care's fixed payments you know um what that represents in terms of like overall health care costs either of uh one cares or in the in the state but specifically one cares costs so like we keep hearing about you know the benefit it is that for this money to be going out ahead of time and we don't know yet how we're going to true up the system for the services that are being provided but anyway i'm just trying to get a sense of what percent of money is now moving um in these prospective payments thank you just this is elena i'm happy to try to take this question um that is a very tricky number to come up with to find the appropriate denominator at what could be a fixed payment um so i don't have a great statistic but what we do know is that of all the health care expenditures and some of those could never be a fixed payment um these one care six payments amount to only seven percent um and that includes medicare which is not a true capitated payment so there's a lot of room to grow here um and and again i don't think it's the right denominator because it fixed over all of the health care expenditures um but that is the back of the envelope um estimate for 2020 it's a very low number and if it was already um uh more scale um at this particular point in time we would be so much better off yeah i i think that's what we're hearing from our network is that if more of their um payments or revenue were actually fixed they would be able to be way more agile right now um and wouldn't be facing some of the financial um concerns that they currently had when they're um operating under a fee for service model so i would agree we need to go farther and i think this is just further proof that our current system that we've spent years and decades um doesn't support us during these type of crisis and then can i just ask a follow-up so because i still don't really have a sense of how much of one carers money is going out in those payments but maybe another question is oh has any other providers other than hospitals are receiving um perspective payments at this point i know there had been six primary care practices but are there more than that yeah i mean vicki i mean you can probably comment on them more recent numbers but per your submission i think you're you're estimating 35 percent of all of the payments of one care statements are fixed and then i we have certainly the breakout in the budget details that were submitted this fall of which providers are are participating or not so stew i'm happy to point you to those resources online all right easy yes yeah that i think but are there more i know that the hospitals are receiving perspective payments and my recollection was that there were six independent primary care practices receiving fixed payments for 2020 and that was from the budget submission but i i just didn't know everything has changed so much so i didn't know if there were any additional ones um if you know that not great i want to follow up offline that's great thanks yeah i think probably just um i don't have the exact numbers susan but there are independent primary care practitioners that do receive the fixed payment and they're actually part of some of the stimulus recruitment we're trying to make because they were under that fixed payment as well yeah i think seven of the 35 independent practices are taking fixed payments and that practice is not positioned yes thank you okay are there other members of the public that wasn't on my end i will say though jess if by any chance i drop off quickly that there's been some severe gusts of wind here as i'm sitting and this morning when i was on another skype event i lost power so if you lose me take over quickly okay so with that i'm gonna thank you vicki and uh i'm going to um now move to the blue cross blue shield non-standard um qhp plan and amaran if you're on the line if you wanted to try to set that up for us sure uh for the record amaran average a lee green mountain care board today's presentation from blue cross blue shield is to present a proposed plan design for their non-standard qhps for the 2021 plan year earlier this year the board adopted a process and criteria to review non-standard plan designs from carriers blue crosses proposed plan design for the 2021 year was um uh was discussed with dfr and diva and dfr made the determination that the proposed changes were sufficient to trigger board review and so today will be a presentation from blue cross and they will be requesting the board review the proposed plan and approve i'm assuming uh requesting that the board approve those changes for their 2021 non-standard plan design and amaran would that vote be today it is scheduled for a potential vote today if the board is comfortable doing so great thank you so with that i'm going to turn it over to rebecca hinds and rebecca if you could um introduce your colleagues and uh proceed with the uh presentation welcome hi thank you hear me okay we can okay so i'm going to have martine who is also um with me along with cathleen kark from um blue cross martine's going to actually present so um i'm not sure if someone has to give her the right to put the slides up or how that works i already did you all have the permission okay great so so those are up um martine you want to put the slides up uh can you see them now no but it says loading now we can great thank you they're still loading for me but i oh here they come okay so we are um here today to uh talk about some um plan design changes that we would like to make and i'll explain kind of why we're here when we don't normally come for the non-standard plans um if we get further into the presentation so uh next slide please feel free to ask me any questions as we go that that is uh no problem at all um so we're going to just do an overview of the market what we already have in place um just to orient everybody and then we will um talk about the proposed changes and then have a discussion on um you know any questions you might have about those changes or about the plans in general and then um hopefully you will feel like you have enough information to vote um just a matter of course these plan designs are uh in front of dfr so they're doing their aca compliance forms review and it's not necessarily dependent that work wouldn't stop if we need to if you need more information but i hopefully will be able to give you everything you need to make a decision today um next slide this is just an overview of our products um we offer all the standard plans um as dictated by diva and the catastrophic plan and then we typically have had um two non-standard um plan design options and the non-standard high deductible plans are are not in front of you today um those have the typical um cost change the cost share changes that are required in order to maintain av values um and those those did not trigger uh green mountain care board review and then we have um three other non-standard plans they they're just different metal levels of the same plan um they're very very similar to what we were previously offering but the benefit enhancements that we're looking at do trigger um review and all like i said i'll go through why um that's the case so if we could go to the next slide again if you have questions so feel free to let me know so the way that the aca is set up is you cannot change a product from one year to the next unless your changes are considered a uniform modification and the idea there is because people are typically auto enrolled into the same plan for the next year the aca regulations protect buyers from getting our dramatically different plans so there's the criteria in the second bullet are what will trigger what allows you to consider something a uniform modification meaning we're going to treat it as the same product even though it's not exactly the same so the company remains the same the network is the same meaning you can't switch you know a epo product to an hmo product and call it the same product um the product covers the same service area and the product has the same covered benefit so those are all um things that we've satisfied and then there's this i think slightly less than clear provision where and i've just this is the actual language from um the regulation that each plan has the same cost sharing structure as before the modification except variations in cost sharing are related solely to changes in cost and utilization of medicare or to maintain the metal tier level described so the just to i think you see some of this from divas presentations every year but every year we all have to go and um recalculate the av values for each of the plans and tinker with the benefits so that they comply with the requirements and i think probably that this this last one that we're not satisfying here um is intended to sort of capture those routine changes to cost share so we are adding some new benefits to our existing um plan design and because of that it doesn't really fall into one of these categories and will be treated as a new plan um in the past uh i think it was just this year that we designed um a process where things that are considered new plans meaning they're not being uniformly modified under this regulation would go to the green mountain care board for review and approval so that's why we're here today are there any questions about sort of that any questions from anyone so we'll go to the next slide non-standard plan that we're talking about today um we used to call this the blue rewards plan and this um is the name that it has this year um it said it's also sometimes internally called the non-standard deductible plan the first bullet shows you our current enrollment in the different metal levels so we have a gold silver and a bronze offering here no platinum um and these are the current enrollment numbers so these are the people that if um this plan design has changed they will be i will work with the fr on this but they would be auto enrolled into this new plan if they didn't switch for any reason um we are going to change the blue rewards name this plan did use to have a monetary incentive to do some um various health screening type wellness activities we did we rolled those back this year so the so we've been struggling a little with the name um for this year so this with the new enhance enhancements we will change the the plan design the plan marketing name if you will um that's not ready yet um and that process is moving along you know we're doing market testing that kind of thing um so the benefits are going to be exactly the same subject to the normal cost shared um changes to keep the eight the actuary value um level correct but there will be new benefits for individuals who are diagnosed with diabetes and heart disease and we've worked with um teams internal teams to come up with a benefit design that we hope will support um higher levels of chronic condition management and compliance and hopefully help people stay healthier with these conditions uh next slide and so these are the design principles that we generally apply when we're designing uh product features you know we want there to be value to the coverage um you know we're always struggling against the best benefits cost the most money um so that's always sort of a balancing act we do know that the market appreciates simplicity customers do not appreciate complex product designs they call a lot when they don't understand their benefits um so we do try to keep benefit design as simple as we can of course in the healthcare world that's you know not always that simple um and then we want to be able to create maintain access to no cost or low cost preventive care primary and behavioral health care visits so those are sort of the the framework that we applied in this in this process of creating this new product designed um next slide so in general we're feeling pretty good about our qhp population preventive care participation here's some you know basic statistics on you know we have 73% of women 50 to 74 getting their mammograms 75% of women having their cervical cancer screening 70% 50 to 75 getting their correct all screening when it's appropriate so we're feeling pretty good about those numbers those are pretty positive we do a lot of outreach campaigns in these areas we have a quality team that's sort of regularly looking at this data and trying to you know increase these numbers we work for providers um so so this is in general we're feeling good about this but we do have 10% the blue crosses qhp population of heart disease and 5% um have diabetes uh next next slide we're looking at opportunities for doing something creative in this space we did take a look at what the state is doing and the various different areas where state entities are working on public health initiatives and here's just a few things that are in place that do recognize diabetes and heart disease as important diseases to try and help people manage more appropriately and we noticed too that the apm has the goal around reducing the prevalence of morbidity of chronic disease including COPD diabetes and hypertension so we felt like these these um disease states were probably appropriate consistent with you know state policy goals and also um hopefully with our member you know interests as well so next slide so we also have um determined that our internal care management programs do pretty well with these numbers that we have good solid programming in these spaces um and so that helped us sort of focus on these conditions and then we had our clinical teams and our customer service teams sit down and talk about what they thought um would help our members that have these disease states um how how they what they were hearing on the phones and what the science shows on um obstacles to managing their care and so that process went on for several months and coming out of that these were the benefit enhancements and these are the things actually that are triggering your review today so we are proposing that we will add three office visits per member with no cost share um to have these diagnoses um for these specialists that were that were um identified by our clinical teams as being the most appropriate to help manage these conditions most effectively um additionally we're adding certain drugs to the wellness drug list which means that they will be subject to cost share but they are not subject to the deductible so you're paying um a percentage of the cost and or COPE I'm not actually sure which it is but instead of having a way to exhaust your deductible for these drugs so it includes insulin and these again were picked based on sort of the science of what's appropriate for these conditions and then additionally we expanded the nutritional counseling limits so there's no limits for the members that have these diagnoses so it might make sense to ask if there's any questions about those benefits specifically we can come back to these of course but any questions about those enhancements? I have a quick one. Any board member have a question go ahead? Yeah just a quick one but the nutritional counseling there's no visit limits is there cost sharing? I believe there would be cost sharing uh Martine or Kathleen is there a question? This is Martine I believe there is cost sharing on these visits. Thank you. What would be a co-pay for a nutritional council? I believe it follows all the other specialists co-payments. We do have um detailed benefits uh on I think it's the next three slides oh no Ashley we'll get in there is detailed in the slide deck there are um the charts that I think you see um when that is in the same format that you typically see when Diva comes and does the standard plan changes um they have this level of detail so if we want to maybe let's go over the next slide just quickly and then we can show bring up one of the detailed slides and maybe take a look at that. So this is just a summary in a chart form of the changes between the 2020 plan designs and the 2021 proposed plan designs up at the top you'll see that there are some modifications to the cost share this is as I said sort of the routine um tinkering that we have to do with the cost share in order to maintain the AV levels um and then here are really the new benefits um the office visits and the wellness drugs and then the um nutritional counseling didn't get on here but um so that's just a summary now if you want to go to the next slide we can bring up a a detailed summary or a detailed chart on the plan design changes so here's the gold plan um and so the specialist office visit um would be $40 for for uh this one now it would be subject to the deductible for the nutritional counseling now in green is what is changing or being added so just a question on the nutritional counseling before was there a limit to the number of visits because if there's still a copay just just wondering what the difference is on the nutritional counseling Kathleen do you know the yeah the current limit was three visits so this would remove that limit and allow the member to access nutritional counseling in you know for more uh sessions okay so before they would have three visits that would have been at the copay and then they would have to pay a hundred percent and now they would get unlimited visits but they would do the copay is that how we should think about that yeah okay great thanks hi Kevin I just want to follow up with Jess's question she beat me to it that you know we're looking here at managing diabetes um as opposed to preventing diabetes and our um our policies that we adopted I think think back in February sometime I emphasize under the category of innovation prevention I'm looking here at Blue Cross Blue Shields bronze plan for the current year and the specialist copayment at that level is $90 in their marketing document whether entitled managing Joe's type two diabetes so I just I just worry that that the focus here is not on prevention where the CDC program which is considered the flagship is a program of nutrition and and fitness and I'm not sure that that this gets us all the way there I would agree that this is not aimed at prevention Blue Cross does have other firms that are not necessarily tied to this particular benefit enhancement involved in you know focusing on prevention we do a lot of work internally talking about how to encourage people to exercise we do a lot of community events or at least we used to do community events to try and encourage people to be active we do kind of monitor some of the you know behaviors that are associated with prevention so there is a lot of activity in this space but for this benefit enhancement this is for people who already have the diagnosis and it's intended to help them manage our chronic conditions I will say that one of the things that we've sort of been talking about internally is a little bit of a gap on the um you know I think wellness and encouraging a healthy lifestyle we've been doing a lot of that work but we are looking at not leaving behind the people that are that do have these diagnoses and not alienating them from that wellness messaging and trying to be mindful of meeting people where they where they are and encouraging even people who might feel like well I'm not healthy enough to do xy and z trying to have messaging that really still speaks to them and encourages them to live their best life wherever they may be from a health perspective but yes this benefit enhancement is for people that are already diagnosed but it's certainly not the only thing that we're doing any other questions from the board no reason can't see the slides uh but I can't either staying here I thought maybe you had taken them down no it's still saying I'm presenting who just said that this is routine um it's still telling me I'm presenting but I can uh I can try again still nothing mine says loading now oh yeah me too there we go I think I might be in the same windstorm as you chair mullen so if it goes out again let me know um so these next two slides are just the same detail so that's this is the gold um and then we have the the silver and the bronze and then um if we want to go to slide 15 we can sort of go through the evaluation criteria so these are the criteria um oh well next slide previous slide 14 I guess it is um these are the criteria um that we have for evaluating the change and so um the substantial difference in deductible or maximum out-of-pocket compared to standard plans this is not really being changed by this benefit enhancement but these plans except for the benefit enhancements have been in place since the beginning so it it's not clear that this criteria is probably really relevant for the benefit enhancement analysis um so substantial cost share differences for one or more highly utilized services compared to standard plans this benefit is not available in the standard plans for people with diabetes or cardiac condition um the plan structure difference compared to standard plan designs again these are unique benefits um compared to what's available on the um standard plans I will note that this benefit here the three uh primary care physician or mental health visits at no cost share this is a something that's been in place with the blue rewards plans since they were first introduced so this is that first part is not new those are staying that benefit remains um and then the qualifying specialist visits that we just talked about um enhances innovation we're excited about um the idea of of focusing benefits on supporting chronic care management um and I think we're going to watch this closely and and if this seems to be doing well we might be you know expanding our the targeted conditions and then um the last one is of value um to promote individual and small business health insurance and again see it there is not currently any product that helps people with these specific conditions so we feel like it does offer something that's not otherwise available any questions about this the criteria and the proposal questions anyone I guess I just have a quick one about that last point will you be specifically marketing to people with diabetes and cardiac conditions and suggesting that they switch over given that there's these benefit enhancements I think I mean the marketing is still underway but I would assume that we are going to encourage people to look at these plans as maybe a more appropriate choice for them versus some of the other plan design thank you so I have a question the as I recall the blue rewards program was that you got a debit card for about 300 bucks if you went through these four relatively uh you know these these four kind of administrative exercises um not physical exercise but you know I think some of them is a kind of a fill out an assessment etc and I'm just wondering about the finances here so there you you're you're terminating blue rewards and that um on a per patient basis allowance was 300 dollars do you know how much you're saving there and how much the reduced cost of the specialist is offset by the savings from blue rewards we did get rid of the blue rewards debit card for this plan year um deep the mark you would probably need to speak more knowledgeably I'm not sure that we have detailed information yet we did get rid of the blue rewards not so much because the cash payments on the debit cards were that expensive you know a lot of people didn't bother to get that benefit but the there did not at all appear to be any connection between improved health and using the doing the steps that you needed to get the the financial reward so we really wanted to try we're really interested in seeing if there are ways to get benefit designs to help have better health outcomes and so we didn't feel like the cash reward was accomplishing that but we did roll that back for the 2020 plan year so that's not available martin do we have any preliminary numbers about how much we hope that you know people's overall health spending for these conditions may improve so we haven't this is martin we haven't done a specific analysis for our members with these diagnoses we um we know you know we for the overall actuarial value of these plans to continue to meet the metal levels we we accounted for these cost share differences in that overall population analysis but we haven't looked at specifically you know member a with diagnoses of diabetes this is what would happen because the ranges of care between members you know we have some members that are currently well-vanaged that might just get that one you know um visit at the podiatrist and will be saving forty dollars so that's not a lot of savings but the fact that they can go to the podiatrist has a lot of value that is beyond just the forty dollar copay and and we're really hoping that these visits will get members to keep up with the managing their conditions so that in the future years they don't have a lot of claims so i don't know that it would be a one-year look that would be very telling if these if these products are are doing what we hope they're both they will do for these members well i would just say you that you're on a better track here than i remember but you're so go looking at the you know the three hundred dollar benefits and seeing where it could be used there was a whole list of different vendors where you know someone could get a massage they could buy a tea time at a golf course and it just seemed to be kind of random activities that weren't tied to any kind of managed plan to move people along with either preventing the diabetes or helping them once they're diagnosed so i'm not i'm not asking the question in order to say gee i missed the three hundred dollar a debit card because um i know a lot of people look at it was a penny but it's it didn't seem to be an investment in preventive health to me i'm excited i i hope you know it would take martin's point it probably will take some time to see um if this makes a difference or not um but we're hopeful you know we in addition to talking to our clinical staff we did talk to our customer service folks about what people were complaining about on the phone as far as barriers to care so this reflects um to some extent people's perception of um you know obstacles that they face more questions i think we have one more slide this is just um our success metrics so these will be the things that you know what we what we're hoping um will occur um you know encouraging members to see the appropriate specialists at the right time really helping to increase medication adherence um including insulin um where we are um you know that we hope to continue to leverage our successful care management programs in this space and we are um working with planning to be working with one care obviously as you heard lots of things are on hold at the moment um for their attributed members um you know hope the wellness activities that we normally have annual screenings that are provided for all the aca compliant plans um so these these are all things that we hope in the totality will really encourage people to um have a better health outcome check my blood any questions about this slide any questions on the board so i is this the ending questions or just the questions on this slide no i think the last the last slide is this slide go right ahead so fire away tom so so um when we met in february uh one of the things that i've noticed and i could be off the wall here but it seems to me that foundational to all of these qhp plans is the benchmark plan that that we have at the federal level and they have opened up the gates a little bit um to allow states to amend that plan um ours goes back to 2015 2014 um and it predates the all-paramodal it predates you know a lot of the reform efforts that uh you know the the state government is trying to encourage and i just um and for example the the one that i focused on back in february was diabetes that uh you know the blueprint runs a cdc diabetes program uh and statewide they only had 184 graduates in 2017 which is a small proportion so you have one of the more severe morbidities um and a program that is kind of like not in the mainstream of of of funding for prevention and so my uh i you know i've asked this almost a year ago and uh is that when uh you know is the vermont's benchmark plan going to be reviewed to have it aligned as to a maximum extent possible with the all-paramodal goals for example um and uh at the meeting in february we actually changed the evaluation criteria for non-standard plans to encourage that so so i guess my my my two questions are are we is diva on a path to try to restructure the benchmark plan for the 2021 year and if not are they looking to do it for the 2022 year which ironically is the last year of the all-paramodal but um it just seems to me that this is a structural component of preventive health that is is uh is way behind the times um well the 2021 year is definitely not not that that ship has sailed on the benchmark plan um we have been talking for a while about um taking another look at the benchmark plan and i i can't speak to diva's plan for um 2022 uh i will say that the basic benefits that are included in the benchmark plan are pretty broad and pretty general it's really in the the biggest levers are really in the cost share space where you can boost somebody's access if you will um by by removing financial barriers the problem that you run into is that when you make a big change in one place you have to make a big change in another place so that your av values are still in line with the requirements so you you are constantly playing this game of of taking from one and giving to the other if you make big changes what we're suggesting here you know is fairly small in the brand scheme of av values so it's not really an issue for these little changes but the to do something big um you've got to give up something so i think that's one of the challenges with doing like a total overhaul of the benchmark plan um but you know if diva does take that up we're definitely interested and excited to participate in that um process and and i think we would probably uh be excited to bring more clinical thinking to that conversation than we have uh than we did you know the first time around they just picked the blue cross plan that happened to be in the market so it is exciting i think it's more than anything it's just it's just having the time well i'll just respond to that a little bit by something that i said um you know last February which was you know in blue cross blue shields current year marketing brochure for the blot blot bronze planet it's so it has a category called managing joe's type two by diabetes and the total example cost is 7400 bucks for a year of which uh five thousand 160 comes out of joe's pocket and it just seems to me when i i look at that uh where versus what it costs the blueprint to operate a cdc sanctioned best in the business prevention plan and uh they're doing it on a shoestring it seems to me that from an av point of view at least in this particular instance you know it it it it it would seem to be a reasonable trade-off i don't know that i know that i've heard people say they don't want to open up the benchmark plan because you know people that that were there back in 2020 2014 say it's a food fight but i just think that we're um missing an opportunity to have our benchmark plan which serves the qhp population as uh finally tuned as possible toward the prevention health kind of goals that we're trying to achieve yes so i'm i've got my fingers crossed for 2021 or 2022 really noted okay other questions or comments from the board i have one but i but i think if somebody else wants to go first that's fine we'll go ahead jess okay um i just you know this plan is obviously going to occupy a unique niche in the qhp market it's going to be catering to you know those with cardiac disease and diabetes so you had mentioned that 10 percent of the qhp population has heart disease and five percent have diabetes so i'm wondering if the marketing is successful um have your actuaries done any modeling on you know what is the expected percentage of the population or expected percentage of the subscribers to this plan that will have heart disease the percentage that will have diabetes um expecting it would probably be above the 10 and the five since it's catering to that and then how then if if those folks see the value in this plan and there's some movement how would it affect the average rent excuse me average risk in the standard qhp plans it's some of the more high risk diabetics and heart disease patients move over i'm going to let martin correct me if i'm wrong but it's my understanding is that the risk is shared amongst the entire pool so when you have people moving from place to place it it where the risk can can be worse or better is when people leave the pool entirely so say all the people leave um the blue cross pool that don't have these conditions and leave only these folks with these conditions that would have an impact but if people are moving it's within blue cross between these um between plan choices it's my understanding that doesn't have any impact on the actual risk pools because of the way that the the pricing works and that the risk sharing works within the merge market martin did i butcher that sufficiently no that was really good maybe you can have a second career in actuarial services um but yes so the the plans the the rules around rating for the plans uh take out the morbidity at the plan level or the the um the risk at the plan level and adjust all of the plans and so it wouldn't if all the you know vermont diabetics decide to go in this one plan that one particular plan is not going to be negatively impacted you know next year when we do increases because that impact will be spread across all of um all of the pool both on the plain side and the risk adjustment side so yeah i knew it would be on the risk adjustments that i was just curious because i'm going to read about some of the claims side but um thank you that clarified that okay robin or marina any questions i'm good thank you yeah i'm good as well thanks so at this point i'm going to open it up to the public for any public comment hey kevin it's walter hey walter what's happening i just live in the dream sheltering in place walter share up me too watching the snow fly outside and the wind blow i just have one question about all these plans we've been talking about is i don't think any there'd be too many people who can afford these plans anyway and what happens to them if they can and don't qualify for medicaid or something like that because you know when you talk out of pocket expenses and ac values and deductibles most people can't afford that so you know i think all these plans are great but you know they're just going to be dangling out there because who's going to pay 90 bucks or as tom said you know it's going to cost them 5 000 a year and none of us are going to have that kind of money especially now with this virus crap going around and this is going to go on for months and months so anyway that's my question i'm not sure that there's a question i can really answer but the you know there is cost share reduction program so the benefits that are the cost sharing levels are adjusted for income i recognize that there's frustration with the level of those subsidies and the level of the cost share reduction program in general and and the whole cliff when you fall off the cliff and you don't qualify for any subsidies and those are obviously part of an ongoing conversation that we're having about the health care system in general but not specific to this proposal i guess oh i haven't seen any oh go ahead don't go ahead walter see i'm on a phone so i haven't seen any of the slides yet but i'm just listening to it you know even with cost sharing reductions it's probably still unaffordable anyway walter well fortunately it's the one piece of insurance product though that does have assistance um through the exchange depending on the uh level of income i mean i i know it's not everything but at least it's something other other public comment this is more watchman just quickly given we had a long discussion about telehealth i wondered whether these visits that are part of this uh plan can be conducted through telehealth which would improve access for folks who don't want to make a trip and many of these visits especially nutrition counseling don't require a lot of physical presence so my understanding is that Blue Cross Blue Shield of Vermont has had telehealth reimbursement parity for a long time and that what we really changed in light of the COVID crisis was um waving HIPAA compliance and paying for telephone visits with no visual and so i think at some point um you know the HIPAA compliance piece is obviously not a Blue Cross Blue Shield um you know it's not up to us the um but on the telephone on telephone visits we are starting to have conversations about where is that that visual part vital and where might it not not be um so we are we are you know keeping a close eye on how this is changing the healthcare system and um you know there's it's it's telephone visits make sense um from a clinical perspective you know i think you'll see some movement from us on that um but again on the on the regular telehealth where you have both audio and visual we have had um a program in place that that allows that and the reimbursement rate is the same for for things that we've that our folks think are clinically appropriate for that type of visit but i think we're taking a fresh look at that list in light of what we're learning and we'll continue to do that other members of the the public hearing none is there a board member who would like to make a motion robin sure um i move approval of the Blue Cross Blue Shield non-standard plan design changes i'll second is there a discussion hearing none uh council barber if you could call the role member you sir yes member column um i vote yes with the hopeful expectation that the next time around next year we will be in the middle of a uh reassessment of the benchmark plan yes member holmes yes member lunge yes mr chair yes thank you rebecca and martin and um at this point we're going to go to all business is there any all business to come before the board hearing none is there any new business to come before the board and i wanted to bring up an item here um we as a board because of the open meeting law are not allowed to have conversations about the hospital budget process in private so i wanted to um just bring up something so that uh it's out there in the public and that my um colleagues on the board could understand um where i'm thinking um for the hospital budget guidance for 2021 and um my thoughts are simply this that because of these unprecedented times with the COVID-19 uh pandemic that uh really this is not the time to be taking any enforcement action on 19 with that being said it's also um 2020 um the year that we're in is also uh a year that isn't going to mean much because the world has changed and what we've seen is an incredible decline in non-covid related um health care in the state of ramon and so um because of that all the hospitals are in uh financial turmoil and trying to deal with the situation so they have been very clear that they do not see um a way to have a traditional budget process and uh so my thoughts are to to delay the submission of the uh budgets till the uh middle of the summer that um it be a simple thing with npr where we did go through the process to grant them their 2020 budgets they're what i'm suggesting is that for npr we strictly say that you're going to get um three and a half percent increase on your 2020 budget for 2021 and we're not going to do any enforcement for 2020 because the enforcement would all be on the downside and it would be inappropriate because of the unprecedented situation that we're in so what i'm suggesting to explain and kind of what i think is an easy way for everyone to understand what i'm proposing is to use as an example um take a hospital that has a fictitious npr that we granted for 2020 of 100 million dollars we would we would grant them an npr for 2021 of 103 million 500 000 and the enforcement for 2021 would be a combination of the two years combined so it would be 203 million 500 000 and um that will deal with whether or not we will have pent up demand there are two conflicting theories on that um some people believe that there's a lot of deferred medical treatment that um has taken place and that will occur in 2021 and then there are some people who believe that this may change um people's perception of getting care and that you may see a continued reduction but in any event um it would give the flexibility to the hospitals to manage um to that 203 million 500 000 level for the hospital with the um 100 million dollar um npr approval for 2020 um i'm not um looking for a debate or anything but i just wanted to throw it out there so that um all my colleagues would know what i'm thinking and um at some point um we will have a meeting and we'll be able to hear um everyone's thoughts and we'll figure this out in a way that recognizes that hospitals are laser focused on dealing with the current crisis and we have to have a budget process for this year that will meet that understanding i did reach out to general counsel to confirm that um because the statute is very clear that we have to do a budget for each year um but we're still doing a budget for 2021 we did a budget for 2020 that this would fall within that i know that some people from the hospital community had proposed to me that we do a two-year budget for 21 and 22 i still don't think that we have legislative authority to do that at this point in time and so um i think what i've laid out um recognizes the abilities that we do have and recognizes the uh the sheer fact that um anything at this point in time is is pure conjecture and meaningless because we don't have enough data and we don't know what the true effects are going to be so is there any new business to come from other members of the board uh Kevin this morning just just want to comment a little bit um on what you're bringing up um knowing that we're not going to make any decisions today i do think the concept of looking at you know what's lost in 2020 to be added to 21 you know and i think the way you laid it out is kind of a simple way to do that i do think that would be a good thing that we may want to look at when we finalize things um also just because i have been working with the staff on um you know what type of budget process we will have and i think we're planning to try to present that on may 6th i think next week there's not going to be necessarily enough time on the calendar so i think we're looking at may 6th so people can kind of look out for that date you know from the hospital piece um i will from a little bit of a preview say that we've engaged um several of the CFOs that um have worked with us in the past just kind of you know on our when we've done things off cycle and have worked with some of the CFOs we gave them a very scaled down um P&L balance sheet type of a submission and it was very favorably received so i was really um happy with the feedback that we got from the CFOs i was even looking at maybe doing something way more scaled back and the staff at gree mountain care board kind of came up with a little bit deeper analysis and when we sent that to the four CFOs that we talked to um they even added a little bit more to it but we're very favorably it was very favorably received by them what we might be requesting so i we all know maureen isn't that um didn't you guys work to try to moral line the reporting with the monthly reporting so that it's all very similar a little bit yes and then there may be some ads to that about some of the the funding that's going to be received because of cold it and how that works um but i was just pleased that look look we all know every budget i've always said anyway every budget is obsolete day one and so you know we we know whatever submissions we have that those budgets um are going to be obsolete and we expect there'll be a much more fluid process i would hope during the year um that said i'm not a hundred percent aligned about you know not having enforcement um so i think we'd have to have further discussions on that i don't expect we're going to have people that are exceeding the numbers and that it's an enforcement where we are imposing um restrictions on their you know what they need to do with an excess i just would have a question or concern about potentially giving up something that we don't know yet about what could happen in the future so and i and i do agree that in the past let me let me be clear what i was talking about was no enforcement for 2020 i get it but i'm not sure i'm a hundred percent there as well until 2020 because um you know there's just so much going on i don't think anyone's going to exceed their number and i'm not anticipating what what would what would be required if some fall so short but the biggest thing here is right making sure that they're all financially viable and sustainable in the long term and and i know everyone's trying to do that so i'm not second guessing that but there's possibilities that maybe the decisions they're making aren't going to get them there and so so where would enforcement come in that's all i'm saying i just you know it could very well be we do nothing under the circumstances i just don't know what the benefit is of coming out with that right now that would be just my point of view on let's see what happens um you know as as time progresses um before we we you know formally say we're not doing that that's the only reason why i can't anticipate what it's going to be but i wouldn't want to look back and say oh boy i wish we hadn't said we weren't going to do anything because you know these two or three hospitals might be going out of business because we didn't get enough funding i mean i'm speculating completely i'm just trying to throw out examples of why you know maybe there's maybe we could be helpful in the enforcement process uh yes i mean that are all of us share the goal of having a healthy healthcare system and we do not want to um see something come out similar to what happened with the state college system this past week and uh i think everybody's got to get in the boat and and row together and uh come out the other side of this with a continued healthy healthcare system and know that this could happen again in the future so we have to learn from everything that we're doing now and um move forward can i just add one thing um and that's just about your point uh Kevin about the data and right now anything that's submitted would not be based in reality and i just want to echo that i mean obviously we don't know if there's going to be another surge uh after we reopen the economy we don't know if there's going to be pent up demand there's so much we don't know and so i guess i would ask a hope that the hospital budget team and you know are thinking about when is the ideal optimal submission date you know you you've mentioned kevin you know mid summer um if we waited a month would the data be more meaningful would there be less uncertainty so i don't know what the optimal date is but my hope is that when the data is submitted it's as meaningful as possible and if waiting a month allows you know more information i would be open to that so i just want to add we should be really focusing a little bit on the meaningfulness and the timing of the data so i would also just add to that though that um you know it could be a different process right we could have um submissions you know delayed a bit from from when we originally had them in some time in the summer you know still giving out budget um you know fulfilling what we need to do from our our statutory requirements for budget but then meeting more frequently or or having touch points whether it's meeting or not during the course of the year because it will be so evolving you know i'm not sure any of us could take a date at any time the rest of this year where a 12-month outlook you know we would have a much better handle right unless we really get a handle on knowing if this is gonna reoccur and what would happen or we would then we still be not doing non-essential all of that right so short of a vaccine yep yeah so so i think the point is and and knowing that there are even with all this uncertainty there's still a need to be doing budgeting and planning and people will be doing that from a staffing side from an expense side and again it's going to be it's going to have a lot of assumptions that won't be correct but they're still going to be doing it and they also need to do it for their banks for their board and things like that so i think we're you know we're trying to be really supportive and what it is but understanding i would envision that it's going to be a lot more conversational when we have the meetings with the hospitals because from whenever they submit to when we meet with them things will have changed and so i think um you know that's my point of view and i just think we'll have to be really open to to that change and knowing during the course of the year um you know there'll probably be lots of there will be lots of uncertainty and you know significant changes could occur but you know the other part too um on delaying too much is you know we have also heard from the insurance side right that they need they would like to have um some visibility into what type of insurance rates that may be approved and maybe in the budgets and um you know we know there's always a catch up there and it's not an exact that they get what that was in the budgets for sure but you know they would like to have visibility on that so we're trying to be cognizant of that piece too when we look at um you know when we look at that so that's just another factor we agree they've been very clear that they believe that um we have to stick to the uh current calendar process in order for them to have a fair shake at the the rate review but at the I just seeing what we're seeing I don't think that's realistic no that may not be but there does have to be a point where the hospitals have a green light on the rates that they're putting in right so so that that's not December right that's not November that's not you know they've basically said even at the hospital level when we've talked to them that they probably need to know need to know is sometime in October maybe by November first but in that timeframe in order to make sure they've got that all in their contracts with the insurance company so I just think we need to understand that part of it too if we push it out too long and then if we do make any determinations that impact insurance requests that may have been you know that they would like um they won't be able to get it it won't be negotiated um you know or we won't be we won't have approved it if we need to so I just think you know when you look at the timelines there's other factors too yep um is there any other new business to come before the board hearing none would someone like to make a motion to adjourn second it's been moved and seconded council barber could you call the roll member homes yes member lunge yes member tell them yes member use for yes mr chair yes thank you everyone and have a great rest of the day um it looks like the sun is actually trying to peek out here um hasn't come out yet but if the wind would stop it could be fairly nice be safe everyone shelter and follow social distancing thank you