 All right, looks like we have everyone. So I'll call to order the GreenMap care boards meeting of August 2nd, 2023. And we have two agenda items today. First is the Interim Director of Healthcare Reform from AHS, Pat Jones. We'll be doing a presentation relating to an update on the all-pair model and then our Director of Health Systems Policy, Sarah Kinzler will provide an update on Act 167. The GreenMap care board provided a press release this week relating to our retention of a consultant who's gonna help with the community engagement process, which we're excited about and that we're glad we got that underway. A huge thanks to the contracting team and everyone that put in all the effort to get there, including our colleagues at AHS. And with that, I'll turn it to our Executive Director for the Executive Director's Report. Thank you, Chair Foster. So this month, the month of August, we're gonna be finishing up our rate review work. Those decisions, the Qualified Health Plan decisions will be out on August 7th. But then we will turn immediately to hospital budgets. The hearings start on next Wednesday, August 9th. And today we're opening up a special public comment period and we're accepting public comments on the FY24 hospital budget submissions. We'll run this comment period through Friday, at actually noon on Friday, August 25th. And the board will begin deliberations on those budgets on Wednesday, August 30th. All the information regarding the hospital budgets can be found on our website under hospital budget. And then if you click on FY24 budgets, you'll see a schedule of the hearings and all of the submissions. And just reach out if anyone needs help finding those. And then as a reminder, we are continuing to accept public comments regarding a next potential model, which we'll hear more about today from Pat Jones. And any of those comments we receive, we do share with our colleagues at AHS and the Governor's Office. And with that, I will turn it back to you, Mr. Chair. Thank you very much. Before we turn to Ms. Jones, I'll take up the meeting minutes from July 14th, 2023. Is there a motion to approve the minutes? I'll move approval. Second. Any board discussion? All those in favor, say aye. Aye. Aye. Aye. And the board unanimously approves the minutes from July 14th. Ms. Jones really needs no introduction. She's one of our favorite people to work with and I'm glad that you're here. Can I really appreciate you doing this, Pat? So I'll turn it to you. Thank you. Thank you so much, Chair Foster. And thanks for letting me come again today to provide additional updates on the potential future model with Medicare. So I think someone will be sharing the slides, I hope. Yeah, I see that happening. Thank you, Sarah. So we can go ahead right to the second slide. We do have some additional information as of yesterday on the timing of the future model with the Center for Medicare and Medicaid Innovation. So they, I think, you know, we've covered this material in the past but they are definitely moving in the direction of multi-state models. So there will not be a Vermont-specific model and they've outlined seven priorities that will be central to the model and I'll talk about those on the next slide. But we do have some additional information on the timing. We learned as of yesterday that CMMI is planning to release more details on the model in early December. And that will come in the form of a notice of funding opportunity. And so when that is released, states will be invited to apply to participate in the model. If Vermont or any other state decides that they do want to seek participation in the model, the proposals or applications will be due in March of 2024. We had mentioned before that CMMI has informed states that full implementation of the model won't occur in 2025 but they're looking to 2026 calendar year 2026 as the first full year for that model. So we're currently negotiating with CMMI on what 2025 will look like. Our hope would be that it would provide a smooth transition to a new model in 2026. And at the same time, we're continuing to discuss the potential 2026 model. So late breaking news on the timing of when that notice of funding opportunity will be released and when applications from states are likely to be to next slide. So you've seen this slide before, but it bears repeating, these are the priorities that CMMI is signaling that they will be looking for in a new model. So the first is that it will include global budgets for hospitals. The second is that they're looking for total cost of care targets in addition to the hospital global budgets. They want a model that is all payers so that includes Medicare, Medicaid and commercial payer participation. They are interested in seeing goals for minimum investments in primary care. So a clear focus on supporting primary care. CMMI wants to see safety net providers engaged in the model from the start. So that includes our critical access hospitals and FQHCs. They want the model to address mental health, substance use disorder and social determinants of health. And they want to see health equity addressed as well. So those are really the seven payment design elements and core principles that we've seen in CMMI's potential future model. Next slide. So this summarizes why are we interested in continuing to include Medicare and Vermont's healthcare reform efforts? First of all, Vermont is a low cost state for Medicare and so having Medicare involved and alternative payment models continues to recognize that status. And similarly, if we continue to have Medicare participation, some of those baseline financial calculations that they might do in a future model would really recognize some of our past reforms that have saved money and also resulted in care delivery improvements. And I'm going to spend a good chunk of my time today talking about some of those reforms and how we're communicating a desire to continue to be able to pursue those. Having Medicare involved as well certainly gives us some ability to influence reimbursement for Vermont's healthcare providers. It also continues the investment from Medicare in the blueprint for health, including payments to primary care practices that have been recognized as patient centered medical homes, investments in community health teams in each region of the state and the support and services at home program that supports Medicare beneficiaries in their homes. So, you know, at the point at which Medicare were not to continue to be involved in alternative payment models with Vermont, those investments for the Medicare portion would go away. We also have some waivers of Medicare regulations that are included in the current model and that we would hope to see in future models and a future model could give us the ability to propose new waivers of regulations as well. And those can support improvements in care delivery. And then finally, the alignment that we see across payers in priorities, payment models, quality measures can be beneficial to our health system and can send a signal to all of our healthcare system partners. Next slide. So, the healthcare reform workgroup that's currently meeting monthly was initiated in June of 2022 and there are a number of subgroups as well. And there are four areas of work that that group outlined. And the first was short-term provider stability that work is ongoing. The second is the impact of the regulatory environment on stability also ongoing. Financial and care model was a third area of work and that's the one that I'd like to focus on today. And then models for long-term hospital stability and that's part of the work that Sarah will be talking about as well today. Next slide. So, we have tried to provide some broad feedback to CMMI as we've engaged in discussions about potential future models. And so some of the really important needs that we've communicated to them include the importance of support for rural provider stability and sustainability with a particular emphasis on the workforce challenges that we're seeing and healthcare inflation impacts. These are not unique to Vermont by any stretch but rural areas can have particular challenges especially in the workforce arena. And so we have emphasized that. The second is the importance on having predictable payments for the healthcare system. A third area of feedback is really relates to Vermont being a low-cost Medicare state and that is ensuring that we attain the right amount of revenue to support healthcare system stability. Support for investments in primary care and community and preventive care and community care is another area that we've emphasized in our discussions making sure that there is alignment across payment models and quality measures as much as possible. I mean, there may be some variation among payers but to the extent that we can align, it is, you know, we've heard repeatedly from our healthcare partners that that is beneficial. And then finally, allowing Vermont to continue to keep moving forward on our important healthcare reform efforts and that includes care for people with complex health and social needs, support for primary care through programs such as the blueprint for health and comprehensive payment reform and support for community-based services. And so what I'd like to do today is really focus my time on the communication we've been providing around support for investments and preventive and community care and allowing us to move forward on those important healthcare reform efforts. Next slide. So the blueprint for health is clearly one of Vermont's signature payment and care delivery reforms. It's been in place statewide since about 2011 and it has really provided some focus on primary care and on care for people with complex needs. So two of the core components for the blueprint for health are support for patient-centered medical homes. These are primary care practices that have been recognized as patient-centered medical homes by the National Committee for Quality Assurance. They meet high quality standards for preventive care, care coordination. And so that is sort of the key building block for the Vermont Blueprint for Health. The second core component is regional community health teams. So in each health service area, there are multidisciplinary teams. They address work to address unmet healthcare needs. They include a wide variety of staff members. The region decides to a great degree what the staffing for community health teams will look like based on their community needs, but frequently it includes nurses, care coordinators, social workers, counselors, health educators and health coaches, registered dieticians, community health workers, et cetera. And in some cases, the staff are located centrally within each health service area and serve as a shared resource, and that can be really helpful for smaller practices in their patients. And in some cases, staff are embedded in practices that have sufficient patient volumes. But the point is to have a multidisciplinary team that really supports patients access to preventive services, coordinated care and care for complex needs. So those were the original core components of the Blueprint for Health, and they continue to exist today. Next slide. The Blueprint has also served as a platform for some additional innovations. And so three of those are outlined here. The first is the hub and spoke program for people with opioid use disorder. And so there are two components to that. It's a Medicaid funded program. And I should have mentioned, actually, on the prior slide that those core services are supported by all payers. So they're supported by Medicare through the current all payer model program, Medicaid, sort of the original supporter, and also our commercial health insurance partners, Blue Cross Blue Shield, MVP and SIGNA. So those two core services are provided and supported by all payers. These services are currently Medicaid supported. But again, the Blueprint has served as a platform for these additional services. So the hubs are managed in the hub and spoke program are managed by the Department of Health, and they provide intensive treatment for people with opioid use disorder. And then there's also community office-based treatment services, and that's what we've referred to as spokes. So often primary care providers, some specialist providers as well, that is supported and managed by the Blueprint and it provides mental health and nursing services for people with opioid use disorder. A second program is what's currently called the Women's Health Initiative, or in the process of thinking about the name of that program, but that really is intended to provide primary care and preventive services for women of child-bearing age around pregnancy and tension. And that's a program that has also been supported by the Blueprint Medicaid funding only, but it allows for screening and brief intervention in offices and then referral to health and community services as needed. And then finally, support and services at home, which has been around the longest of these three initiatives. This is actually Medicare, largely Medicare funded, but it provides wellness nurses and care managers to serve Medicare beneficiaries, elderly and disabled folks who either live in congregate housing or in nearby communities. So it provides extra resources for those Medicare beneficiaries. Next slide. I think most of you know that we are engaged in an expansion of the Blueprint program at this point in time, so we're expanding funding on the Legislature-approved Medicaid funding to implement a two-year pilot. The goal here is to improve access to mental health and substance use disorder services and to address social determinants of health by integrating resources with primary care. And the rationale for that is that, you know, we're experiencing increased deaths from drug overdose and suicide. And you know, there's concerning levels of acuity as well for mental health and substance use disorders. So a real need to provide additional resources in primary care to help meet those complex needs. We also feel we need to really focus on identifying and addressing social determinants of health and housing instability as an area that we believe needs particular focus. And the objective here is really to make sure that there are additional services and supports within primary care that can be used to serve all the entire population in the practice. Next slide. So that summarizes the blueprint for health and that's, you know, we've really focused hard in our discussions with CMMI on the need to preserve those programs and investments. And in addition, Medicaid, the Medicaid program has developed a number of alternative payment models for a variety of services. And that's been really, you know, supported by the health care reform work and the current model. And so we again want to make sure that we're continuing to support these innovations as well. So there are eight different payment reform projects that are currently managed by Medicaid, includes the Vermont Medicaid Next Generation ACO program, which is the Medicaid component of all payer model. We also have a mental health payment reform initiative that provides an alternative payment model for adult and children's mental health services provided by our designated mental health agencies. We have an alternative payment model for residential substance use disorder programs. We have a model for applied behavior analysis for children living with autism. There's an alternative payment model there as well. In earlier stages of implementation, but a very complex project relates to services for people with developmental disabilities. So we've done some significant preliminary work there. That one is still in the design phase. Children's integrated services, providing services for early childhood. That has an alternative payment model as well. One of our newer projects is a high technology nursing services payment reform initiative for both children and adults who are living in their homes and reliant on high tech services. That's with the home health agencies. It's a small program, but an interesting alternative payment model there. And then the Brattleboro Retreat also has an alternative payment model. So while there's a lot of talk right now about hospital global budgets, because that's one of the key elements of the model that we expect CMMI to put forth, we think it's critically important that we continue to have support for predictable, reliable payments that allow flexibility in how care is delivered and the blueprint is emblematic of that and these payment reform initiatives are emblematic of that as well. So really, Vermont thinking about health care reform is really thinking about the whole system and our home and community-based providers primary care as well as hospitals. Next slide. Another area that we've tried to communicate with CMMI about is around, and I had mentioned it in an earlier slide, but waivers of certain Medicare regulations. Some of these waivers can really help support improvements in care delivery. And an example of that is that in our current model, there's a waiver of, there's a requirement that there be a three-day inpatient stay prior to someone who is eligible for Medicare-covered post-hospital services in a skilled nursing facility. So our current model has a waiver of that requirement that there be that three-day inpatient hospital stay. So that's an example. Sometimes there's some regulations that can be improved upon. And so we're in the process of communicating with CMMI around what some additional waivers. Some are in our current model. Some are waivers that were part of the public health emergency that we think it makes sense to continue. Others are waivers that we're seeing CMMI offer in other alternative programs. And so we think it's really important to have some options there to support improvements in care delivery. So we have the work group, and then there was a subgroup that looked carefully at potential waiver requests and highlighted areas of greatest interest and will be communicating those to CMMI. We already have and hope to have some flexibility there. Next slide. And then another area that we're quite interested in, and I think nationally this is an area of interest, but how do we support successful coordination among providers to reduce fragmentation but to also support good care coordination when it's happening? And so one area that we've looked at is what are some measures that are currently in place that really demonstrate good coordination between two or more providers on behalf of people with complex health needs? And we're calling them shared interest measures or shared interest payments. So some of the measures that we have, again, have communicated to CMMI that we have interest and include readmissions, follow-up after hospitalization for mental illness, follow-up after ED visits for mental illness and follow-up after ED visits for substance use disorder. And then there's a set of measures called prevention quality indicators that look at potentially avoidable hospitalization for people with conditions that can be managed and are sensitive to ambulatory care. So these all look at, you know, what's happening, someone's in the hospital, what's happening in the community when they leave the hospital, how can we, or they're in the community when we prevent hospitalization? So it really speaks to the work between hospital providers and community-based providers. Now, certainly the first four measures are currently in a number of our models. So, you know, we've already got them in place, but the question is how can we use performance on these to encourage and support good coordination among providers? Next slide. So next steps, we will continue to meet with CMMI. We're continuing to gather input from our work groups, from advisory groups at both the AHS and the Green Mountain Care Board, you know, from these presentations, public comments, as Susan mentioned earlier. And, you know, when the time comes, when that model is actually released and we have more detail and it's public, we will be carefully reviewing it to see if it is a model that is beneficial to Vermont and we'll continue to gather input as we formulate that response for early in 2024. And I think that is the close of my slides. I think there's a timeline slide actually. Yeah. So, you know, this just reiterates the timeline, the tentative timeline. Again, we now have a little more information as of yesterday. Fall of 2023 is actually looking like early December of 2023. And then March of 2024 is when those applications would be due from interested states. We'll continue to, you know, inform you all as we begin to move forward on that. Then later in 2024, there would be negotiations with CMMI trying at this point to understand what 2025 will look like. And then if there's a decision made to move forward by both us and CMMI, then 2026 is when that multi-state model is intended to launch. So I think that is the end of my slides. Thank you again for the chance to speak to you today. Thank you, Ms. Jones. I had one question, which I think I know the answer to, but maybe for others. On your timeline slide for the bridge year of 2025, can you speak to sort of the expected timeline on when we'll have a sense of what that might look like? And I know it's actively being negotiated, so it might not be totally clear. Yeah. I would certainly hope that by the end of this year, we would have a very good sense of what 2025 is going to look like. We're hearing from CMMI that, you know, I think it's safe to say around the end of the year, they have clearance processes that they have to go through if there are any changes. You know, we're in active discussion with them, but I would say the end of the year would be a good bet. Thank you. Any other comments or questions from board members? I have a quick question, if that's all right. Tara Foster. Please. Pat, thank you so much. It's always wonderful to see you here, and thanks for your continued hard work for the state. So appreciated. I'm wondering if you can just talk about CMMI's appetite to provide transformational resources to help providers, you know, shift from fee for service to global budgets, any talk of a federal state funding match as we had in the last model? Yeah, I can't, I have no specifics and can't give you any specifics, but I can tell you that it is a priority topic of discussion. And I put it into two buckets. One is, you know, transformation dollars for the state because there will be some, obviously some changes that need to be made if we embark on a new model, but more importantly, transformation dollars for providers to make those changes in care delivery, payment models, and so forth. So I can't tell you, you know, any details, but I can tell you that it is an area that we have talked about with them. And, you know, I haven't gotten the sense that they do not have an appetite for it. So I think they understand that, you know, changes of the magnitude that we're looking at with some of these models, whether it's the, you know, the model that we're talking with them about or other multi-state models, that they really are a heavy lift for providers and so hopefully that will translate into support for care delivery transformation. Yeah. I mean, my thought was, I was largely thinking about the provider community and the transformational dollars there. Have we done any internal estimates on what we think the transformational cost might be so that we can make that ask or include that in our proposal or, you know, do we have any internal estimates of what it would take to transform our system? Yeah. I can't say we have firm estimates at this point in time. I will tell you that, you know, and we don't have details about the model either, but I think that's a good recommendation. So when we get a bit more detail as we talk to our partners, I think it's an important question to ask. So thank you. Oh, great. And I guess my final question is just, I know we had hoped that this NOFA would be out in fall. Now it sounds like it's December. Do you and your team feel like the turnaround time, December to March, is, I mean, what does that look like in terms of being able to digest the model and then be able to put together a reasonable app? Does that feel like that's doable? I guess it must be. Yeah, it feels like it's going to be a very busy holiday season. But we, you know, part of the work we've been doing to date is to try and, you know, begin to build our thoughts around what kind of a model would work for us. Getting feedback from various participants in the healthcare system. And so I do think that, you know, we weren't sure if we were going to get a two-month turnaround or a three-month turnaround. We had heard anywhere from 60 to 90 days, and it looks like based on what was released yesterday that we are, that states will have 90 days to respond. And again, I'll emphasize should they decide to apply for this program. So 90 days feels better than 60 days. It still feels like a pretty rapid timeframe given that, you know, we'll be getting details later. And I guess you can still call it fall because it's before the first official day of winter, but it is later than what we thought it was going to be. Well, it was 48 degrees this morning when I woke up, and I would say that doesn't seem like August, whatever weather to me. Yeah. So 90 days feels better than 60. Yeah. Well, I'm glad to hear that. I'm glad to hear that. Thanks for all your hard work on this, Pat. Thank you. I have a couple of comments and a question. And Pat, it's a little bit of a, and aside from the main topic, but anytime we talk about the blueprint programs, I just really feel I need to comment on them. And my other life working as an emergency physician, I cannot tell you the importance of these programs and the lives of the patients that I see. And I just, there's a few that you brought up that I just want to talk about real quickly, the community health teams, care coordination, social workers, dietitians. These are the impact, these are so hard, the impact of these is so hard to measure, but the impact is so palpable. And so I think this gets a little bit complicated in health policy conversations, and we're wanting to try to figure out the measurement to measure the benefits of these programs. But to the people's lives that they touch, they're just, they're massive, they're incredible, and they're hard to measure because they're very intangible things that I think are hard to define a metric. So I'd still just encourage and to continue with them, I'm just so happy that they're available. The hub and spoke model and the access that it provides, which, you know, it's difficult to staff, but it's still, again, incredible difference in people's lives to be able to get treatment for opiate use disorder and now expanding it to alcohol use. We've been really fortunate in the state that the Bratable Retreat has been able to return their capacity, the bed capacity they have back up to what I think was, it was prior to COVID, went down for a while, which has made a huge difference in mental health boarding and emergency departments throughout the state. But again, I really can't emphasize enough my appreciation for the pilot program to improve outpatient mental health capacity that you discussed. When working clinically, this is just a daily thing that we experience that patients need more access to outpatient mental health resources. The need is so, so massive and the impact is so important. One thing I wanted to bring up that I see in my work is one of the metrics that we rely on is the ED, follow-up after ED, visit for substance use disorder and alcohol use disorder. And I'm very fortunate to work in a place where we have great recovery coaches in the region and they do the majority of that work. And I think do it quite effectively, but I think they don't get counted because they're not filing claims. So I actually think probably the work that we're doing in the state and the successes we're having is beyond what we're capturing in claims because so many people are following up with recovery coaches and getting involved in a culture of recovery. And yes, it's, you know, there's no way they can get 100% success rate, but if they get a 10% success rate, it's a better intervention than so much of we have in healthcare. So it's really important. Those are sort of my comments. And this is a comment slash question, but one thing I struggle with a little bit is that being a low cost Medicare state and a relatively high cost commercial state and a lot of the discussion that's gone over the years about how that has come to be, how do we know that we are, we're getting the right amount of Medicare revenue for the work that's being done to care for the Medicare population? Yeah, I think, you know, I think the way we're looking at that is it's really going to be important. If we are already low costs and, you know, it's multifactorial, I'm sure, but it's, you know, the use of services, keeping people at home rather than in the hospital. I mean, one of the findings in a recent evaluation report from CMMI that showed that the current model is in fact saving Medicare dollars is that there were fewer acute hospital admissions and fewer acute hospital days. And so, but there are other factors too. I think it's a lot of it's the way that healthcare is practiced in the state and some of it might be those other supports that you talked about that you're seeing from the blueprint and other programs. But the really important thing from our perspective is to make sure that when you're already low cost, finding more savings is going to be a challenge. And so that balance between obviously we all want healthcare to be as affordable as possible, but understanding that if we're already low cost, finding more savings in Medicare could be a challenge. And so a reasonable approach to that from Medicare from CMS is what we would seek. And thank you for the comments on the blueprint resources as well and the Brattleboro Retreat Alternative Payment Model. I will definitely pass that along to my colleagues who support and lead those programs over here. But thank you. Thanks, Pat. Pat, I'll just turn to healthcare advocate in case they have any questions or comments and then we'll do the public comment today at the end of the presentations. And Mr. Becker, how are you? Well, Chair Foster, thank you. Just to thank you to Pat Jones for the presentation. Other than that, we have no specific comments. Thank you. Great. Thank you. All right. Thank you very much, Miss Jones. Appreciate your time today and for the update. And next we'll hear from Sarah Kinsler on the Act 167 work with Global Payment Model Development and Hospital Sustainability Work. Miss Kinsler. Hello, all. Thank you so much for having me before the board today. For the record, this is Sarah Kinsler, Director of Health Systems Policy at the board. So I'm going to follow Pat's update with a kind of coordinated update continuing down the rest of the Act 167, sections one and two work streams. So as a reminder today, Pat presented on our green box here all at last week or excuse me, last month, or perhaps even the very end of June. I haven't quite gotten used to it being August yet. I provided an update on kind of the rest of the work. We're undertaking under Act 167 sections one and two. Today that update will be a little bit more focused. I should note that Pat and I are going to try to bring these tag team updates back to the board. Every month or so, or every, you know, four to six weeks over the course of the next few months so that we can keep the board and the public updated on this work because there's a lot, a lot going on. And we want to make sure that you're all aware of that progress and have opportunities to, to ask questions and provide your input. So today I'll, I'll repeat a little bit of what I said last time I was here regarding the global budget work. And then I have some information to share about the community and provider engagement efforts for hospital transformation, which chair foster alluded to at the beginning of the meeting. So on the global budget tag, I, I'm, and I'm being a little bit repetitive here because I think it pairs repeating because this work is very complex. So I want to, I want to continue to highlight there's some very active technical work happening behind the scenes, you know, in, in engagement with the office of the healthcare advocate with representatives of hospitals with representatives of payers with representatives of unions and other, other entities as well. So we're working on kind of technical design, planning and options. And so I want to keep talking about this work, even though not all that much has changed since late June. We were forced to cancel a meeting and push our work back a little bit due to the flooding. And so this is kind of continuing, continuing to evolve. We are having our technical advisory group react to a straw model for members of the public. I should note that the straw model is presented as slides. Are now posted on the, on the tag website. So anyone can go explore that with us. That was a first exploration of kind of a how it could work. In the meantime, over the rest of the summer in the fall, we're going to really keep tackling key issues as we continue to improve our data and improve our straw model. Some of those issues are going to be supporting care transformation. So thinking about the work and how to ensure that any global budget model could support broader care transformation. The work that Pat discussed earlier, the terms of payer participation and how that might vary across payer types and between payers within the same payer type, terms of hospital participation, budget calculation and payment options. So really talking about the administrative functions as well as monitoring and evaluation, which is going to be a critical topic that we'll be getting to in the last quarter of the year. And some key areas of the methodology that I hope that, you know, we will engage board members on in the coming month. And again, you know, the same slide that I presented in June is we're really going to want to talk about these critical pieces of the next methodology, like the base budget and how to set annual trends and adjustments, how we move forward from that base year and how we, how we balance our goals of keeping up with inflation and costs and ensuring it's a sustainable payment model while also factoring in affordability and ensuring that from others can can afford to pay for their health care. The regulatory mechanism, a question you're in here to our hearts, I know, as well as the quality framework, monitoring and evaluation and and really how do we, how do we tie quality to payment, but what's the broader monitoring and evaluation mechanisms so that we can make sure that we are closely following this work and, and really seeing the impact across the system. So that's all on global budgets. Again, that work is, you know, very active and will continue to be through the fall. The outcome of that work is kind of draft technical document that we can review more broadly and we'll be working more closely with, you know, a broader set of, of providers and ensuring that, you know, hospitals have a chance to get really familiar with what is being discussed so that we can get in depth feedback from across the system. So on the community and provider engagement work to support hospital transformation, this is Act 167 Section 2. In Act 167, the Legislature directs the Green Mountain Care Board to, to post convene a data informed patient focused community inclusive engagement process for Vermont hospitals. This has been the topic of much discussion as we've gone through kind of the procurement and contracting process. And we last month signed a contract with Oliver Wein and a consulting firm that is has significant expertise in health system design and transformation, significant expertise in facilitating complex community conversations. And also has worked in Vermont for a very long time as a contractor for the Department of Financial Regulation. They led the wait time study that happened here two ago. So this is a contractor that we think knows Vermont very well and will be able to really ably lead this process. They will be reviewing data and soliciting local input and really developing options to ensure that Vermonters have sustained access to affordable care. They will be going out into communities to host large public meetings as well as doing kind of more targeted engagement with, you know, hospitals themselves as well as other key stakeholders. In addition, a current contractor, Mathematica Policy Research will be providing data analytics support. Member Holmes to the question that you asked earlier of Pat in terms of an estimate of the cost of that legislation. That is actually part of Act 167, Section 2, and it's something that we are kind of required to price out as part of that legislation. So that's something that's built into these contracts to have these contractors working together to help us figure out, you know, for the solutions that all the linemen is proposing. What is that cost? What is the cost of state? What are the cost providers? So hopefully that gets us at least part of the discussion. There is more information available on the page that I've linked on these slides about the process itself as well as a way to sign up to get more information about these public meetings that will be held. So the team that has led this, and I would really love to shout out Marissa Melamed and Hilary Watson on our team and managing these contracts. They're an incredible team that has really put so much work into this and into kind of announcing this launch yesterday. So Hilary and Marissa were able to set up a form on our website so that folks were interested, whether that be members of the public who are attending our meeting today, legislators and the constituents, people who work for healthcare organizations, really anyone who's interested in hearing more information about these meetings and seeing the materials and attending these meetings when they happen is welcome to sign up and you can sign up to kind of receive alerts about meetings that would occur in your community. So community meetings are resided to begin in the fall. Outreach and scheduling will begin this month. The contract officially launched yesterday, August 1st. So we're diving right into it and we are excited to see where that will land. And board members will certainly be working with you to ensure that we can get your attendance at those meetings as well. And to conclude, I wanted to offer a kind of updated version of the slide that I presented in June talking about highlighting those opportunities both for places where we know we will want board member input and we'll be seeking your feedback for the Altair model for global budgets and for the community engagement effort as well as opportunities for the public. So focusing on the purple column, we really hope that board members as well as a robust and diverse group of community stakeholders will be attending public meetings so that we can directly hear the feedback from communities as well as providing feedback on priorities and options for the public side. We want these community meetings to be in depth and robust. So to do that we really encourage folks to sign up for updates and express your interest and we'll also be for Oliver Wyman, I should say, we'll be working through different community groups and contacts to ensure robust dissemination there as well. And that's all I have for you today. Thank you very much. I don't have any questions. I'll make one comment which is I'm really glad that the care board got this work going before I got here because we are now in the midst of rate review and we've received the hospital budgets and you can see how imperative and critical this work is. And so just a huge thanks to all of you that got this work in progress. So it's nothing we have to deal with right now and it's already underway because rate requests are really high this year. Hospital budget requests are really high and so this work is really timely and I'm glad it's underway. So thank you all for doing that. Any other board member questions or comments from Miss Kinsler? Great. Mr. Becker, do you have anything? Hi, Chair Foster. No, just I thank you to Sarah Kinsler for the update and as you said I'm excited to see this work moving forward and looking forward to attending some of these public engagement meetings in the fall. So thank you very much. Great. And I think it will be really critical to get as broad public engagement as we can. I mean, it'd be really we need to make sure that we do that, that we get small businesses, local businesses, community members, patients, everybody so that that whole spectrum of voices is involved in this process. We set out a press release this week about it and I think we may need to make sure that we're getting that because it's really critical to make this work succeed. I'll turn it to public comment via the raise the hand function. I see claps from Mr. Carpenter, so I'll acknowledge that as a public comment. No, it's wrong. I'm on a new iPad here. Oh, no, bro. Just one question. Exactly what is patient centered? I ask this as a as a former patient and a patient. Miss Kinsler, Miss Jones, do you have a would you like to respond to that question? I'll be glad to give it a try, but you know, it would certainly welcome others as well. And I assume that the references to patient centered medical homes I think, you know, for, you know, the idea is that care is delivered in a way that meets the person's needs that allows them to choose who delivers the care how the care is delivered and one of the key elements in the patient centered medical home recognition requirements is that they should be well coordinated among providers. Someone with complex needs might be receiving care from a variety of care providers and so we would want them to, you know, have input as to who do they see as sort of their primary care provider primary person delivering care who is on their care team who from their family or from their circle is part of that care team and how can that care be delivered in the most coordinated way that's responsive to their needs. I mean, in essence you know, the person should be directing their care. And if I might add I interpreted your question a little bit differently Mr. Carpenter. Thanks Walter. Also referring as also referring to the legislative language of kind of a patient centered community or excuse me data informed patient focused and community inclusive engagement process and and how I'm kind of conceiving of that if that would be helpful. Well, I was thinking that the patient is so often referred to as a consumer. So how was patient centered different from patient as a consumer or is it one in the same thing under a different umbrella in this particular the legislature does it you know Congress does it I see it all the time. Yeah, that's absolutely the case and I think that the consumer language has been kind of more info over the past few years. But you know, maybe that that pendulum shifting a little bit in terms of the act 167 community engagement process I think of the legislature's instruction here of is as really being it needs to have the individuals experience of care at the center of our thinking as we think about what a healthcare system could look like in the future and that we really cannot just be collecting feedback from you know organizations whether they be you know provider organizations or payers or the lobbying groups or even the advocates we really need to hear directly from Vermonters about their needs and what they think is most critical to have locally in their communities and how they would advocate for their healthcare experience to transform in their healthcare organizations to transform. I think I was working a little off Dave Merman's comments about the blueprint and stuff and what that does for people and why can't we think of the whole healthcare system along those lines rather than this patient centered or other terms all yield the floor we need more David Merman's agreed Owen I share Sarah's view that to me patient centered means that this process of informing ourselves of how to do this work means the patients are participants and inform us of their experiences and that we have that view that's driving some of the outcome and suggestions and thinking in this process so starting with the patient what are they getting what are they not getting what are their experiences and informing ourselves about that because I think that's your point and I think it's really important I'll turn real quick to member Walsh because he has hand went up and then the next hand is Miss Aron off and then Mr Hoffman. Thanks for foster and hello Walter I just wanted to take a moment to take a stab at your question I agree with everything the Pat Sarah and Owen have said I think in addition to what they've said what in my clinical work and in my policy work things that I've written the kind of the rules when we think about patient centered what that is trying to do is to to make providers aware that we need to document our efforts to better understand what matters most to patients and then oftentimes when they when treatment decisions need to be made there's more than one option we have multiple options to choose from for a given condition and those different options have different risks different benefits and two people with the same condition facing the same options may choose differently depending on their values and throughout the history of health care the decision about what treatment to pursue was deferred to the provider it's only been since the mid 2000s that we've started saying hey we need to document that we've engaged patients and try to understand what matters most to them we've gone to great lengths to explain the options that are available and we've helped them uncover their values and then we reviewed those values in the decisions we move forward with so that's the long winded answer I'd say it's not seen much yet it's talked about a lot but you may not have experienced it much yet I haven't experienced it much in my care but it's aspirational and that's what we're trying to do and to figure out ways to better who can do it well I agree I also read your article in the Washington was it monthly but as a patient I know you are limited by the choices of what your insurance has for one there is no such thing as patient choice or patient it's what the insurer wants whether it's name a wall that's what it is you know this doctor that doctor but you can't go to that doctor this doctor it's a contract it's a monopoly that we're seeing on and on that's why I ask because it's a great idea if it's centered on the patient but the patient has no choices except what insurance dictates for them in general we've got a long way to go Walter and I appreciate you raising the question 410 on a long way to go Tom okay okay Ms. Arnoff Mr. Hoffman you guys switch places on my numbering here yeah that was my fidgety hand and I've got a two o'clock meeting that I'm actually a participant in so I just will be very brief really Pat this is a shout out to you for your rundown of those payment reforms there are stories behind every single one of those those high tech nurses for those parents oh my god the stories I've heard over the years the parents who are entitled to 10 hours 50 hours 100 hours whatever to keep their babies alive and can't get the nurses because the rates are too low so kudos and shout out for those payment reforms and for the work that you're doing my request at this time so history doesn't repeat itself is that when you say safety net providers will be included from the start I'm hoping and assuming that those safety net provide and health equity is a thing I'm hoping that you will reach out to the health equity advisory committee and to the developmental disabilities council and to some of us others on the scene and bring us in so that we don't go through an all payer model repeat where there's a plan we all know what happened with the Medicaid pathway and the money that went to the ACOs and not to the designated and specialized services agencies and everyone's misbelief that there was going to be 180 million or whatever it was on that slide out there so let's not do that again and please include us us disability advocates and thanks so much for the work that you've been doing and are doing that paying parents stuff that came in during the pandemic keeping that alive that is just so vital to our community and before I run Mr. Chair I'd just like to put out a request to you that sometime during the coming months you consider holding a panel similar to the ones that you've held with other groups but I don't know if people on the Green Mountain Care Board know it but people with disabilities make up Vermont's largest health disparity group and people with disabilities have a lot of ideas low-hanging fruit about what could improve services and what could make things better and I would be happy to work with someone else on putting together a panel on the needs across the life cycle because if a person has a disability the family has a disability and I think that educating the board on the needs of people with disabilities would be a great service I'd be happy to be part of putting together. Great yeah good suggestion thank you for your comment and now you and Susan can be in touch Mr. Hoffman thank you for your patience please go ahead I think you're muted I'm muted now Mr. Hoffman can you try and speak let me try something here Kristen are you on somebody with more text could you try and unmute Mr. Hoffman just to see if it's on our end I don't have the ability to unmute individuals can you hear me can you hear me you can yes that sounds great okay I switched over to my mobile so I wanted to speak to Dr. Merman's point as far as Vermont being a low Medicare spend state you know it reminds me of when he asked during the ACO budget process if ED savings in the Berlin HSA were the result of interventions or poor access and we really don't know Miss Jones similar to the NORC report responded with some ideas that could be might be possibly be drivers but we don't know and as I requested since 2019 with this board a rigorous approach would be to run a regression analysis between well documented declines and access but we're very aware of those declines now well established we have year over year data lots of rich data increased ED utilization particularly at the academic medical center well documented and then actual outcomes so run a regression analysis between those the most important outcome which you all have never run but I would again repeat my request that you do is CDC data is showing increased mortality rates and we can run a regression analysis between those and access so that's a rigorous response to a very valid request by one of your own board members you have a team with a team of data analysts some of them exceptionally thinking of this particular you can run this data and find out why or at least rule out that similar to his suspicion that poor access in the Burlington HSA is not the real driver low Medicare spent so would love to see that run at some time see you guys put some of this great horsepower you have to use the other is a question with blue cross blue shield Vermont confirming last week they're not returning to the ACO what are we hearing from CMMI while taxpayers fund CMMI as well as all of you the public has no communication with CMMI you are its proxy CMCB specifically is in the all pair model agreement so what is CMMI's posture to one third of potential attributed lives not being in the model interventions or transparent will you offer us today in terms of letting the public know if and what CMMI to this confirmation responded with for instance now that we've confirmed two years drivers can we pause for a second sorry this is so trippy requested since 2019 sorry one second we're on like between well documented clients it's like there's a digital delay in a reverb I wonder if we were just getting this first device I think it went off mute so he was talking on two devices I think it might be better now chair foster sorry about that Mr. Hoffman there was a delay from your old device coming through the party so I think you left off where I last heard clarity was yeah yeah the last thing I heard with clarity before it was doubling up was CMMI no process for public comment with CMMI for the public to engage with CMMI and you were asking about the posture with CMMI to the ACL that's where the last part I heard yeah so with the confirmation of year two one-third of attributed lives being out of the model that would be a triggering event per the all-payer model agreement which ordinarily would necessitate a corrective action plan that we have the confirmation I suppose we can wait till 2025 to then look back and say two years of failed scale I would say that the scale waiver for the state is not dispositive in terms of this additional loss of Blue Cross lives so this is not covered under that previous scale target waiver so what if anything will you share in terms of feedback CMMI again the taxpayers funds and that you act as proxy for has given in terms of its concerns about one-third of commercial or basically all commercial lives not being in the model particularly what is the impact of that for 2025 bridge year so how do you even begin to vision a bridge year moreover beyond the bridge year if we don't even know how we're getting one-third of remoners into the model is it anything you all would be willing to share today with the public since we can't access CMMI I think I'll say first I have heard of some public comment and communication with CMMI I don't know how much bandwidth they have but I have heard of public speaking with CMMI on some of these issues anyway and I'll ask Miss Jones and Miss Kinsler if there's anything that they can share on this question because I think it's a relevant one but some of the negotiations necessarily are confidential because we can't share where they are where we are until they have gone through the clearance process but I'll turn to Miss Jones or Miss Kinsler if there's anything that we're permitted to share at this time with regard to Mr. Hoffman's question Yeah I don't have a lot to share I can't speak for CMMI in terms of their level of concern I can say that they're aware that Blue Cross is not participating with the ACO when we think about 2025 the focus in those discussions really is on Medicare Medicare's participation in alternative payment models Thank you and I'll turn to any new business or old business to come before the board and I have some that I wanted to bring up if Miss Sawyer or Mr. McCracken are here I think Mr. McCracken you got to run pretty quickly so I'll try and keep this limited Oh and you forgive me I just have one question when will the rate decision be made I don't see it on the calendar the Blue Cross are the rate decision I'm not sure when that will be published I think pretty soon I believe in rate review team Mike Barber back me up but I believe August 7 they'll be released Yeah so pretty quick Alright so I'll turn to Miss Sawyer and Miss McCracken we had on June 14 there was a motion and a vote relating to one care executive salaries if you have any slides relating to what we had decided on June 14 do you have the actual language from that hearing is that visible Yeah so the second condition that the board approved related to the compensation for one care's executives and the language here I'll read it it conditioned the approval of the amendment to one care's fiscal year 23 budget on the requirement that one care modify its fiscal year 23 budget by capping compensation for one care's executives VP level and above at the median 50th percentile of the benchmark used by one care to establish its executive compensation amounts budgeted by one care for executive compensation and excess of the media must be allocated instead to one care population health activities and there's some vagueness in some of this language about capping the total compensation and whether or not that should be at the individual level or the aggregate level and I want to clarify that and modify it so that the cap would be in total for the aggregate level and what I mean by that is that the absolute dollar amount spent on the budget for executives would be at the 50th percentile but if one care chose to pay one person at the 60th and somebody else at the 40th that would be permissible and it would be at the aggregated level and the same amount of money would actually be allocated to one care population health activities and so I had a motion I want to propose to make this modification to clarify this condition and what I'm going to do is I'll read the motion and we can open it up for public comment for a week and then we can take up the motion next week to see if there's a second and to vote on it if there is but the motion language proposed for us to consider for next week is I've moved to modify the second condition in the Green Mountain Care Board's June 14 approval of one care's revised budget so that the cap on executive compensation established in the condition shall be calculated and enforced on an aggregated basis capping the total combined compensation for one care's executives VP level and above in one care's fiscal year 23 budget at the total combined amount of the median 50th percentile of the benchmark used by one care to establish the compensation for those executives the condition is otherwise unchanged I believe Mr. McCracken has a meeting at 2.30 so I want to read that and we can have board discussion next week and we can take any public comment between now and then on this adjustment and that's all I had on this is there any other new or old business is there a motion to adjourn I move to adjourn second all those in favor all right motion carries and thank you everyone for your work and we'll see you I guess next week right have a good afternoon