 Good afternoon, everyone. I hope that the board members had a chance to grab something quickly to eat. And it was a pretty fast-paced time period in between here. But that's okay. And this afternoon's meeting is really focused on response to COVID-19 by the carriers. And I have to say that people have continued to impress and surpass expectations during this crisis. And in my limited conversations with insurers, I want to thank them for the quick actions that they have taken, whether it was giving people the ability to get 180-day fills of prescriptions, whether it was loosening the rules on telehealth, at a time when they, too, were trying to grapple with stay-at-home orders and how to do things remotely, trying to do everything within their power to make sure that there was not a huge lag in payments to providers. These are things that have truly impressed me that people have really come to the forefront. And before we even hear from them, I want to thank them on behalf of all Vermonters for what has been done so far. With that in mind, we also have a point in time now where we have seen providers losing revenues, sometimes more than half of their previous revenues. And it's a time where we know that under the Affordable Care Act, there has to be at least an 80 percent MLR ratio for the QHP offerings, but also it's a time for us to reflect on what could be done to make sure if. And I have to say if there is a windfall to insurers. We don't know. We don't know if there will be a drop-off of membership. We don't know the final results. But it's a good place to start to have the conversation. And it really should be a comprehensive one where everyone is at the table and trying to have that discussion. But the main point for today was to get input from all the three major carriers on what they have done in response to COVID today and really to learn from them. And the great starting place is with our commissioner from the Department of Financial Regulation. And I have to say that Mike P. Jack has stepped up from the beginning of this crisis, has really done Yeoman's work in creating data analytics to look at so people are making intelligent decisions. And just someone that I always respected before, but my respect for him has grown and leaps and bounds over the course of the past six weeks, I guess. And with that, we're going to start this afternoon with Commissioner P. Jack and Mike, are you ready and do you have control so that you can share your presentation? We're not hearing anything from you, Mike. Well, Mike tries to figure out how to get control of his presentation and we can hear him. I'm going to turn it over to Susan Barrett for a quick executive director's report, which I was going to save to the end. We are nimble here. Thank you, Mr. Chair. And I know that Commissioner P. Jack is on the line and he does have a presentation that I think Abigail can help him put up on the screen and share as well as put up on our website for those on the line to follow along. I have a few brief announcements. First, that our May schedule is posted on our website. Our meetings for May are subject to change and some are to be determined, but just to announce here in a public setting that on May 6th, Wednesday at 1pm, the board will discuss updated budget guidance for 2021. In response to the COVID-19 pandemic, we have gone back and updated our budget guidance, so that's the topic on May 6th. On May 13th at 1pm, we're going to hear from an outside expert who does national work across the country on national trends in state affordability and sustainability strategies. This is something we've been working on well before the COVID pandemic, and I think it will be very interesting in light of the pandemic to hear what he has to say. And then on Wednesday, May 20th, we have a primary care advisory group meeting scheduled at 5pm in the evening till 7pm. All of these meetings are via Skype and all of the information is listed on our website under our May public board meeting press release. I also want to announce that after the meeting we had this morning, we have posted a special public comment period for a rate increase request from Northwest Medical Center that public comment period has begun and is in effect until Monday, May 4th at 8am. And all of the information and materials can be found on our website under special public comment period. And I think I can turn it back to you, Mr. Chair. Hopefully Commissioner Pichek is on the line. So before we go back to Commissioner Pichek, I'm going to do a couple of things. We're going to take a vote on the minutes of April 22nd. And also, Susan, I'm going to throw it back to you to call the attendance so that Abigail can have an accurate record of who is participating today. Sure. Members of the board, is there a motion on the minutes of Wednesday, April 22nd? So moved. Second. It's been moved and seconded to approve the minutes of Wednesday, April 22nd without any deletions, corrections, or additions. Is there any discussion? Seeing none, all those in favor signify by saying aye. Aye. Any opposed? Okay, Susan, if you could take the attendance. Sure. I'm going to call out the last four numbers of the phone number that I see on our line, and I'll start with three, two, one, two. If you could let me know who that belongs to. Yes, hi. It's Kathy Mahoney. Thank you, Kathy. And then we have seven, six, three, two. Hi, Susan. This is Jeff Thiemann from the Hospital Association. Hi, Jeff. We have three, four, five, two. This is Rebecca Copan with Blue Cross Blue Shield of Vermont. Okay. We have five, oops. Sorry about that. My screen is, we have 2307. Hi, this is Don George from Blue Cross Blue Shield of Vermont. Thank you. I think I did 5572. Three, three, zero. Christine Cooney from SIGNA. Okay. Thank you. Two, four, three, eight. Two, three, four, eight. Oops, two, four, three, eight. Sorry. Okay, great. And then I think I just had, I think I've gotten everybody. I also see Pierce Lingenfelter. Yes, that's Dr. Pierce. Okay. And then we have Nolan Langwell. Orca Media. Looks like we have Dr. Wasserman and Susan Grickowski. I think all of the presenters are also listed on our agenda. Sarah Teachout. Is there anyone else that we are missing or joined since I called out the numbers? Hi, Anthony Cali from SIGNA has joined as well. Great. Go ahead. I'm going to call it CVM Medical Center. Thank you. Josh Playbim Blue Cross in the phone. Hi, Josh. Okay, anyone else? Yep. Kate Mack and Josh Blue Cross. And for MVP, we have Dr. Kim Kilby and Rich Oderizzi on as well. Thank you, Susan. Anyone else? If not, I'm going to try one more time to throw it back to commissioner P check. And Mike, are you able to grab control of the screen? Mike, can you hear me? Now you should be able to hear me. Can you hear me now? Yes, I can. Thank you. Sorry about that. You know, sometimes technology is our friend and sometimes not so much. So I am on my iPad, which seems to have worked for the audio and the visual. And I'm going to try to share my screen on my desktop for the presentation. And I hope that will work. I can also, this is Susan Barrett. I can send a copy to all of the board members and it will be, I think if it hasn't already, it's been posted to our website. But let's see if we can share it. If you can't share it, commissioner P check. Abigail can go ahead and share it for you. That would be great. Yeah, it looks like there's some privacy settings on my computer that's making it challenging. Great. Abigail, can you go ahead and do that? I'm doing it now. Great. Thank you, Abigail. Okay. Can everyone see that? We can. Great. Well, again, thank you. Thank you, chair Mullen. Thank you to the members of the Green Mountain care board and those in attendance as well. Really appreciate the opportunity for the department to talk a little bit about what we've been up to on the healthcare side over the last six weeks. I did hear at the beginning chair the comments that you made to the industry stakeholders and I'll just reiterate those off the top of the bat that, you know, we have been really pleased with the amount of communication and the amount of cooperation that we've received over the last six weeks. You know, it's always important to have communication. It's always important to have cooperation, but in times of crisis, it's sometimes difficult to maintain that and facilitate that in a thoughtful and collaborative way. And certainly some folks on my team, Sebastian and Emily have done a great job helping keep that discussion alive, but certainly willing participants on the insurer side and on the other state stakeholder side have been critical as well. So I do want to thank everyone at the top here. So Abigail, we could go to the first slide. I just will talk a little bit about the basically the two things that I was hoping to cover here. One was to talk about the emergency actions that the department has taken to date from the beginning of the pandemic here in Vermont in early March up through last week. And then also talk a little bit about the financial impacts that COVID-19 is having on health insurers. And for that piece of it, you know, I'm really talking at a sort of a 30,000 foot view and talking about information that we have at a national level. And the reason I'm doing that is just because there's so much that's volatile at this point, both in terms of the severity of all these different sort of metrics that I'll talk about. And also the timing of them, we don't know on the severity front if we'll see a sort of a peak of cost over the summer or whether that will be over the fall and winter or whether we're really in for a longer experience like 18 months for a number of these different metrics, whether they're health metrics or economic metrics. So I will talk about that in a broad sense and give you a sense of where our insurance companies were going into the crisis, the various elements that are going to impact them because of the crisis. And then it's certainly an open question about, you know, where do they all stand now and where are they all going? I think we can all say with confidence they went into the crisis in a good financial position and we're all comfortable and confident that they will emerge from their crisis in a strong financial position and continue to be able to deliver the important services and work that they do for Vermonters. So Abigail, we can go down the next slide. This is really just overviewing the process that the department has had in place since the beginning of March. I mentioned it has been a collaborative and thoughtful process. Since March 9, we've had weekly DFR stakeholder meetings. Again, Sebastian and Emily have taken the lead on that and done a great job of getting a lot of good feedback and also getting a lot of good buy-in from all of these critical stakeholders. We really are discussing operational issues, but discussing policy issues as they've come about and been implemented as well. And we have representatives from the provider community, from the commercial insurance marketplace, other state representatives as well. So that's been a critical key in all of this. We've also received strong legislative support, so we appreciate that. Elements of what we've done, we already had previous legal authority for. We were able to receive agreement on other items, but the legislature also provided us some additional authorization, particularly around telemedicine cost treatment or cautionary for COVID-19 and also some authority around cost sharing for pharmaceuticals, which we'll get into. But their responsiveness and work has been great as well, so that's what you like to see in a crisis is people stepping up and pitching in. So Abigail, if we could go to the next slide. This is really talking about the actions that DFR took in early March through mid-March. But right out of the gate, the department issued a bulletin that required commercial insurers to cover the cost of COVID-19 testing, whether those tests are performed at a testing center approved by the CDC or the Vermont Health Department with no co-payment, co-insurance, or deductible. So we thought this was a really important thing to do early on to make sure there were not financial barriers to getting testing, that people had confidence in that. Medicare and Medicaid were able to provide similar assurances based on the way their programs were already structured. And then the state of Vermont also committed to picking up the cost of anyone that's uninsured as well. So we really were able to get sort of a wide universal coverage on the testing front, which was an important consideration early on in the pandemic. Similarly, in mid-March, we took another action that we thought was important, both from a policy standpoint, but also from a, you know, from a, just attacking the disease standpoint, trying to get people to be as safe as possible and secure in their homes and as possible. So this was a prescription drug refill. The chair mentioned this at the top. We basically had a requirement that an individual could have at least a 30-day supply, but there was additional flexibility at the individual pharmacy level as well to go out much beyond that. So this, again, an important policy initiative so that people are making less trips to the pharmacy, particularly those that are vulnerable. They may very well want to be staying home and staying safe. They might not have pharmaceuticals mailed to them or delivered to them. So this allows them to get a sufficient supply for their important medication and ensuring that they don't have to go out and do that with regularity. We also reached an agreement in mid-March about expanded coverage and reimbursement for telemedicine, making that expand to telephone-only email facts were clinically appropriate. So that was an agreement that we reached. We also came out with an emergency rule, which I will mention in a minute. So I think Abigail, we can go to the next slide. So these are the actions that we took in mid-March to late-March. We suspended the routine provider audits by insurers. So we wanted providers to be able to focus on the pandemic full attention that they didn't have, that they weren't required to be responding to the things that didn't have an immediacy in terms of its impact or its importance. Obviously, these audits are important, but given the current situation and status, I thought that those could be delayed to allow providers the opportunity to fully focus on their work. So those routine provider audits were suspended. Similarly, we suspended the credentialing verification practices for insurers. Under telemedicine, a lot of different providers opened up because some people may be living in New Hampshire but getting treated in Vermont. But now they're getting treated in New Hampshire because they're not visiting the doctor's office. They're staying in their home in New Hampshire. And vice versa, we have borders, obviously, that have a lot of people that travel across them with great frequency. So it was important to make sure that the credentialing requirements were able to facilitate this reimbursement during the state of emergency. Again, another important sort of policy framework. We also put out requests for flexibility around grace periods on premium payments. So we left it to the health insurers to figure out what that means for themselves and their financial position. But basically those that are in a position of not being able to pay due to financial circumstances, you know, there is some ability to have some flexibility there. Similarly with our banks and our credit unions, you know, they want to provide flexibility to those that are really facing severe hardship. But of course, we need to continue to have people that can continue to pay to pay so that all of our financial institutions are in a position to continue to pay, to continue to provide the services that they are and to provide any flexibility that they can. So Abigail, we go to the next slide. This sort of wraps up the DFR work. We issued the emergency telehealth regulation in late March, like we had mentioned, we had reached a previous agreement on that. Again, a very helpful item. On April 14, we issued an emergency regulation relating to the diagnosis treatment and prevention of COVID-19. So this is not just the testing but also the treatment and that was retroactive to March 13, the date of the state of emergency. So any Vermonter that has required hospitalization or other inpatient care that is a member of, you know, one of our commercial insurers in a fully funded plan will not have any cost shares associated in the future. And we'll have that money reimbursed if paid out from a visit in March as well. So that, again, was a critical policy choice, not just sort of the right thing to do, but also eliminates financial barriers for people to get the treatment that they need so that they can get better health outcomes and be seen more quickly. Again, in an effort to get our hands around this pandemic as quickly as possible. So the right thing to do, like I said, but also an important piece of the puzzle in terms of fighting the virus and the pandemic. We also issued a bulletin regarding the payment for out of network ambulance services. This was clarifying some confusion around when an out of network ambulance service provides an emergency medical treatment to a member. It's our view that under Vermont law, the requirement is for the health insurer to reimburse the ambulance provider directly for the cost of those services rather than having the payment run through the member. That has provided some, that has presented some confusion we understand in the past and wanted to provide that with some clarity. The only other item that is on the radar at the current moment is around emergency rules on on pharmacy cost sharing. We were granted this authority under Act 91 that I mentioned earlier. I know there was some testimony on this item as well. From our perspective, we're trying to make sure we understand the population that potentially would be impacted by waving the pharmacy cost share. People that have had their incomes go away are significantly depleted. There are opportunities for them to get on Medicaid and have a cost sharing arrangement, not just on pharmacy, but on other medical services that's probably more beneficial than a commercial policy. So that's a population, obviously that we're all concerned if somebody loses their job, but there's options for them as the current framework exists. Also, somebody that might have a chronic medical condition. Again, it's likely that they've already hit their deductible for plan year 2020. At this point, due to how low the out of pocket costs are in Vermont, I think it's just over $1400 for the deductible. So, again, with those sort of two populations, we think already having options available to them, we're looking at whether we need to do any action in this space. And if action is needed, trying to make it as narrowly tailored as possible so that we are getting a benefit to those that population that we think needs this benefit. We will have more to come on that, but that is sort of a should be determined at this moment. So Abigail, if we go to the next slide, basically everything I just ran through was was everything the department has done and happy to take questions now or take questions at the end as well. But I do want to transition into the financial impact component. And again, I'm going to keep this high level and and obviously every insurer that you'll hear from today will have an opportunity to expand on this or be more specific about their situation to the extent that they would like to be are comfortable doing so at this moment. But this is a snapshot of where are the three insurers that you'll hear today and the three major insurers in the Vermont marketplace stood as of the end of the year 2019. And you'll see that Blue Cross Blue Shield MVP and SIGNA, they all had healthy surpluses. They all had strong risk based capital ratios. We've just put them in there as a range. And you'll see again that they are in a solid position. We talked about, I think you're all familiar with the risk based capital ratio, but just to put a finer point on that for anyone else that's listening. This is a ratio that is used by insurance regulators across the country from a regulatory standpoint when things when the RBC gets into the 200s or quickly falls into the 200s or even 300s. There are certain regulatory actions that are either allowed or required, particularly when it falls into the 100s or below. So when a company is sitting in the 500s or 400s, you know, that is a solid place to exist. Sometimes we want to see a company based on a particular risk factor to be higher to be in the 600s or potentially even in the 700s, depending on the risk factors. But it's safe to say that going into the crisis, our insurance companies were in a strong financial position. So we can go to the next slide Abigail. This is really again the high level analysis of what are the headwinds that are facing insurers across the country, but also obviously those in Vermont as well. So if we take, you know, their pre COVID-19 financial condition and then think about what are the things that have impacted them over the last four months or so, certainly at the top of that list are COVID-19 related claims. So that's both on the testing and on the treatment side. So on the testing side, you know, Vermont has done about 15,000 tests, obviously not all of those tests were done by people that belong to a fully inferred commercial plan, but there's 15,000 tests that have been conducted. So there is an expense there, but the state is also like every other state looking to ramp up its ability to conduct more tests with more frequency as part of the reopening strategy. So the testing and the expenses associated with testing will certainly be around for quite some time. A greater expense though, obviously is the treatment. Treatment can be quite expensive. We'll talk about that again on some national figures in a minute, but the treatment can be quite expensive. Obviously we've had people requiring hospitalization, requiring ICU treatment, requiring ventilators, people that are still in the hospital today and people that will unfortunately need hospital care for COVID-19 likely throughout the summer and into the fall and winter. The real question is how severe will the virus be in the summer and how severe will the virus be in the fall and the winter. Those are just question marks that we can't answer at this time. But obviously if we have a severe second wave, regardless of if that's in October or November or if we have a resurgence in the summer, that's obviously going to have an impact on the financial side. In terms of getting everybody treated and getting everybody the medical care that they need. So those are two items at the top of the list that again have some variability as it relates to the severity of how much more will be required of health insurers from a financial standpoint and the timing of that as well. The investment portfolio performance again another measure that's important to watch. We'll get into this in more detail, but obviously I think everyone has watched their own retirement account knows that the stock market has not performed well over the course of 2020. We are back a little bit in April. It's back a little bit today as well. So it's trending in the right direction, but it's still down at least double digits from its high point earlier in the year. So most of our health insurers like a lot of our insurance companies more broadly have a more limited exposure to the equity markets, but still there's an impact there when you're talking about an impact on the general financial condition. Some of the emergency regulations that we've issued also have a financial component specifically I'm thinking of the treatment zero cost share. You know, the treatment again is expensive and and to eliminate the cost share certainly has a price tag with it as well. Again, we think it's certainly the right policy and the right decision and is helping us fight the virus. But it's important to remember that that also comes with a price tag. Looking into the future a little bit. There are a couple of items that were included in the cares act that was passed in late March. That impacts commercial insurers one is the definition, definitional change or clarification that a COVID-19 vaccine would be considered a preventative service and therefore provided to an individual at zero cost share. So if you can think of that and think of when a vaccine might be online, let's assume it's the same price as the blue shot, which very well could be more expensive. But, you know, you might be talking about millions and millions of dollars in order to get everybody their vaccine when that comes online. So again, that's a cost that's out there. We don't know when we don't know how much that cost will be. We don't know when that will be incurred, but it's something that exists that we have to take into account. The same thing with the serological testing. So this is the testing that is done after the fact to determine if somebody has antibodies in their blood for the virus. We haven't had widespread serological testing in Vermont. But again, the cares act included language around providing those serological tests from commercial insurers with the zero cost share. So something else from a price tag and financial impact standpoint that we need to be mindful of. So those are all the things that have impacted insurers, you know, from a from a negative financial standpoint. One thing that has obviously impacted providers from a negative financial impact is the reduction in non coded 19 related activity claims treatments, elective surgeries and the like. That has something that has accrued to the benefit of health insurers, because again, those claims are not coming in. But the question there again remains, you know, if we do have a reopening of elective surgeries over the summertime, and people are comfortable going to the hospital and getting the surgeries. You know, to what degree does this pent up demand get met completely in the summer or in the fall or in the winter, or to what extent the sum of that demand fall off. To what extent do we not have enough capacity in our hospital system to do all of the current demand plus the pent up demand. That's just an open question as to what will happen when we get back to sort of a new normal standpoint. Again, in terms of the severity and in terms of the timing, both of those things are unknown at this point, but it's something we have to watch closely. So, Abigail, we go to the next slide. There is an opportunity here just to provide some specific numbers at least from a national standpoint to put some context around some of these items we just talked about. So, you can see the Centers for Medicare and Medicaid Services CMS published a reimbursement payment for Medicare. And that was about $35 for CDC approved tests and a little bit more for non CDC approved tests so you can get a sense of what the cost is from a Medicare reimbursement standpoint. Commercial, sorry, some national hospitals I have seen charging $100 to $150 to $200 to run a COVID lab test. So the price is a little bit variable there, but I think it's safe to say that it's not an insignificant expense. So, to add in some of the other requirements under the CARES Act, things like payments for services and screenings that are provided sort of ancillary to a COVID test. Then again, there can be some greater impact from our health insurers. The treatment side of it, the treatment side I mentioned is more expensive and you can get this picture pretty clearly, I think. There are a few surveys out there. One suggests that the cost of an in-person seven day stay per patient is about $38,000. So, you take that and figure how many people have been in the hospital and how many people are going to require hospitalization over the next few months to the next year, depending on when a vaccine is available and or end or more treatment, better treatment is available. And that is not obviously an insignificant number. I've seen other estimates that put the cost of a hospital stay even more significantly higher than that, almost double over $70,000. So again, that's a real impact that I know our health insurers are watching closely as are we. If we can go to the next slide Abigail, this will talk about the investment component. I mentioned that again, this is from the information as of the filings that these companies have made at the end of the year. And it just really talks about their investment portfolios and what percentage of their investment portfolios are in the bond market, in the equity market, or in some alternative market or in cash. And you can see that all of the insurers have the greatest share of their portfolio in the bond market. I'll talk about this in a minute, but the bond market has had some mixed results with certain bonds performing favorably others, not as much. So it's been a mixed result, but probably not going to see much of an impact from that bond perspective, at least relative to the equities. The equities, like I said, they have been hit a little bit harder. And then the alternative investments that companies might have is really dependent on what are in those alternatives. But if we can go to the next slide, I'll just again briefly show what has sort of been the impact. You'll see that on the bond performance, corporate bonds strong corporate bonds government bonds have performed well corporate bonds or high yield bonds that are not as you know corporate bonds are not as strong or high yield bonds have not performed as well. So depending on the mixture that a company nationally has, that will depend on how the performance is on that metric. From an equity standpoint, you can see the S&P 500 again is down this year, double digits about 12%, although it's up again today. And it's bouncing back from its low. But again, that will have an impact on companies financial position as well. And we don't know what the economic future holds I think is everyone on the phone can appreciate. We don't know if we will quickly rebound from a real economy standpoint and whether the financial markets will follow suit. Don't know if there will be a slower recovery or what that financial and economic recovery looks like. So that again is something that we have to keep a close eye on as we go forward. If we go to the next slide Abigail, this will talk about just a couple of other financial impacts I'll hit on very quickly. Again, we already touched on this, but there's some requirements under the CARES Act and the emergency actions that the department has taken that will have a financial impact to these insurers. Mostly around the testing for the vaccine or sorry the testing for serological testing, but then also the vaccine under the CARES Act. I think most prominently the waiver of cost sharing for the treatment diagnosis and prevention of COVID-19 as well. So we go to the next slide. This is really shifting again. We have been talking about all of the impacts for health insurers. Now we're really looking at the impacts to providers in terms of negative consequences. And to health insurers these are really in some way viewed could be viewed as short term benefits. But again, we have to see what how long these drastic reductions in claims last and how quickly they rebound and how they rebound when things get back to a more normal state. But you'll see here this is the number of visits to ambulatory practices beginning sometime in the middle part of February. Again, this is national data companies might want to provide a more specific analysis of how they're experiencing this. But you can see how it drops off quite precipitously right around the time that the states of emergencies are being declared across the country. And the virus is getting more severe and elective surgeries are being postponed and drops all the way down to just about 60%. So pretty significant drop off nationally. You can see that it has stabilized and even ticked up a little bit. That could be, you know, a number of reasons better familiarity and use of telemedicine. Maybe there are some, there's some greater comfort now that some places haven't experienced the virus as significantly as others for people to go into the hospital or other facilities to get treatment. But obviously it's still rather significant and far off the base that it was expected in late February. So Abigail, we go to the next slide. This is really looking at it on a regional basis. So again, not great news for us here in the Northeast, but I think because we experienced COVID-19 so severely compared to some other parts in the country. Not really Vermont fortunately, but certainly New York and certainly Connecticut and Rhode Island and Massachusetts. You can see that the number of visits in the Northeast and the Mid-Atlantic are actually the decline is the greatest in the country here in New England and the Mid-Atlantic states. So again, I think this can be attributable to the impact of the virus more globally in our region. The swift action that governors took to stop elective surgeries and such and even hospital systems took to prevent elective surgeries. I think the combination of that quick early intervention along with some more significant virus spread in the Northeast probably is attributing to that more significant impact here. And then if we can go to the last slide, Abigail, this is talking about how does telemedicine factor into this. And you can see that telemedicine helps improve the number of claims, if you will, if you're thinking about it from a who's getting a health care, who needs health care that's getting it and from a provider perspective, it's improving slightly. But again, this is national data and it suggests that there are still a significant number of claims that are not treatments or visits that are not happening that would normally have happened during the last let's call it four to five weeks. And, you know, there's a couple of considerations there we talked about the timing of all of this what when do we get back to a more than normal state. Do we really have the capacity to not just get to 100 on this chart but to exceed 100 to sort of make up for some of that pent up demand I think that's yet to be seen. I think what also is yet to be seen is will there be what will the impacts be of individuals who didn't get wellness visits didn't get early intervention in some of their care. And do they have more significant and severe non COVID related medical incidents over the next few months that, you know, have an impact on everything that we've talked about today so that's again something that we have to keep in mind and keep a close eye on. But, you know, I don't think we will have the answers to these important questions for, you know, probably many months, if we're lucky, but could be beyond that as well. So I think that is everything I wanted to touch upon chair molland, if you were the other board members have any questions I'm obviously happy to take those. Thank you, Mike. It was an excellent primer on what you're seeing and I realized that we have to make decisions based on realistic data, and there's just not enough of it yet. I can tell you though from what I'm hearing and seeing when in our discussions and overview of hospitals that certainly the five or 10 or whatever percent that is unnecessary utilization has been taken out of the system. And, you know, these numbers are actually low in comparison to some of the drops in revenues that we're hearing from independent practices and from hospitals. And, you know, I received my check from my auto insurer the other day for two months reduction in premium, and it seems like we have to walk very, very carefully. But if we walk too slowly, are there chances that there will be allowed a windfall to carriers because not everyone will be treated equally and fairly. So for example, we have, and I know you're aware of this, but in our rate process we get to look at the individual small group and large group, but we don't get to look at the ERISA plans. And will there be a windfall for some of the carriers in those ERISA plans if there isn't some type of enforcement action taken by DFR? So good question. And just to set the context on the auto side just so everyone is familiar, you know, Allstate was the first out of the gate with providing a refund. Those refunds had to be approved by our department. We quickly within two hours approved the Allstate plan and we put out a press release saying we encouraged all other insurers to follow suit. We intentionally provided flexibility so that they could decide what was appropriate for them and their customers. We now have 90% of the market on the auto side with an approved plan that equals about $15 million in refunds to vermonitors. So that's a great thing. But the thing that I think we want to keep in mind about auto insurance and even commercial insurance and worker comp as well because we're working on those areas. There are people that just don't have the same risk profile, whether it's because you're driving less or because your business isn't open or because your employees are furloughed. That the same risk that presented in February just doesn't exist in March and April. So on the PNC side, that's very clear. I mean, you can, you know for certainty that, you know, the significant decline in driving will mean those claims will never happen. You know, there's not going to be an uptick in driving. And even if there is, you know, you're not going to see claims that are outpacing what has already, you know, gone away in terms of normal claim volume. So we're very confident in the PNC side that, you know, these policy holders paid for 12 months of coverage and they're likely only going to need nine and a half months of coverage because two and a half months of which they were locked up at home and, you know, a stay home, stay state forward or just, you know, protecting themselves and staying home anyway. So that's not as clear. That picture is not as clear on the health insurer side. They're, you know, unlike the PNC marketplace with auto insurers, they're not right in the middle of this hurricane that's circling around everyone. The health insurers are they're dealing with the COVID-19 response. They're dealing with those claims. But then they're also dealing with all of this other sort of fallout that everybody else is dealing with as well. So we want to make sure ultimately that our health insurers are strong, that they are solvent, that they're able to take care of all of their customers. And I'm confident that they can do that. And we will just need more time to determine if there's going to be any windfall, so to speak, to insurance companies. As it relates to the ERISA funds. Just to follow up on that, though, Mike, what we do know is that there has been a tremendous drop in utilization over the last six weeks and likely to continue for a while further. We're also hearing from hospital executives like Steve Lefler and Tom Dee, who believe very strongly that there's going to be an inherent fear of remonters to go into doctors' offices and hospitals for some time to come until there are sufficient treatments and vaccines and that it may not be a short-term effect. The auto insurers gave us a two-month rebate. It seems likely that there ought to be some analogy to the health insurers as far as some type of short-term rebate that could occur. So I just wanted to get your thoughts on that as well. Sorry, I had an anxious dog in here, so he had to go out. Oh, we've all been through that over the last six weeks. He didn't like your question. I don't know. But so, yeah, so I just, again, I think it's not, I think that analysis could very well prove to be true that even if elective surgeries are allowed to begin again in June, there might be remonters that are uncomfortable going to the hospital. So you might not even be back to full capacity. And then the question is also what ability is there to make up for the claims that have dropped off, you know, over the last six weeks or so. So I think both of those are sounds. We just don't know if that's going to happen. We just don't know what that progression will be. And it could very well be that, you know, we see a second wave that's significant and the insurers are being leaned on in a way that we don't currently anticipate. So, again, unlike auto insurers where we don't think they're going to be hit with some something specific to the pandemic that they're going to have to pay out losses because of some specific pandemic related issue. We do know that that's likely going to be the case for health insurers. So because they're right in the middle of this scenario, we really, in my opinion, we really want to make sure that they are well capitalized and strong financially. And then, you know, if at the appropriate point it becomes clear that there was an overpayment or there will definitely be, you know, an excess of premium compared to claims. And I think it's totally appropriate to have those conversations. But again, I just think it's just a little too early with all the variables out there. Does DFR have the ability to retroactively seek a rebate for ERISA plans? So ERISA plans would be a little bit different, right? Because ultimately the risk is lying in those self-funded plans with businesses. So we really don't, as a state, not just us, but, you know, any state actor really have much authority over those ERISA plans. So even if we wanted to order a rebate now or wanted to do something like that, we have, we're quite limited by federal law in that point, unfortunately. Okay. Questions from the board? I have a quick one. I'll start with Maureen first. Thanks. First, I think your presentation was really well done. It was really clear. And I liked the financial impacts for health insurance slide because I think that's something that, you know, we can track back to in the future. I agree. There's so many unknowns. We don't know yet how things will play out. So, you know, hopefully we won't use all the money and tap into those, tap into their surpluses deeply and hopefully we'll have some excess that may go back to the consumers. But just a question on, and I don't know who would be over this, but on the cost of the test where some hospitals are charging $150 to $200 and wondering what regulation we could get on, you know, to make sure that there's not price gouging there and that it's really just covering, you know, what is the cost of the test knowing there may be some offsets for being possibly underpaid by other payers. But, you know, we certainly wouldn't want hospitals to be able to charge what they want there because they know they're going to get 100% reimbursement. So don't know if you have any visibility in what you've been doing on that. Yeah, that's, it's a fair question. And I'll just make sure I emphasize it that those numbers I picked out were not Vermont hospitals. Those were intentionally outside of Vermont. So it's something that's worth us looking at in all honesty and fairness, just to make sure that there isn't, you know, bad practices going on. But that hasn't been something that we've noticed to date. And, you know, I'm sure the health insurers could probably talk a little bit more about that and what they're seeing in terms of the claims that they're paying and the relationships that they have with the providers. But if there is an issue, I think something worth looking at. Great. Okay. Thanks. That's all I have at this good presentation. Thank you. Tom. I'm Michael. I'm telling you. Hi, Tom. Just a quick one. So do you have any thoughts about how looking longer down the road, the current events will affect the kind of actuarial trends that we use in the regulatory process. Have we learned from other pandemics, is there a path that people can refer to, or is this something that's going to be kind of made up when we get there? Yeah, so I'll answer that in a couple of ways. I mean, from previous pandemics, I did, you know, we were talking to one of our outside actuaries this week and they referenced the experience that South Korea had with SARS probably about a decade ago. And how it took them, you know, number of years, three years to get back to a place where certain surgeries were back at the same levels prior to SARS and whether that was due to inability to perform those surgeries for whatever reason or capacity of the hospitals or just a fear for people to go into the hospital. You know, so that's something that we do want to look at is both the medium and the long term impact of how the pandemic will change the demand and interest in medical services from consumers. The other thing that I think will change is this interest and reliability on telemedicine. I do, I mean, I don't know what your experience is and what you're hearing, but from what I hear it seems like people that I would have suspected would be really frustrated with telemedicine have said, you know, it's worked pretty well actually and it's pretty effective for the stuff that's pretty straightforward. So I would imagine that the delivery of health care is also going to be, you know, something that we have to think about in the future as well and that will have an impact as a result of this. Do you have another question, Tom? No. Okay, Robin. Sorry. Hi Mike, how are you? Good Robin, how are you? I'm well, thank you. I was curious to know, and this may be more appropriate for the insurers, but I'll throw it out there so they can be thinking about it while you decide to pass. But have you thought about or talked with any of your actuaries about the impact of the claims lag in terms of the timing of from when we will be seeing some of the COVID related claims because of course, typically what we do when we're doing estimates of spending here, for example, for the all pair model, we use a six month claim lag. So, now I think a large part of the claims are submitted much faster than that, but I think that's something that we need to factor into our thinking when we're trying to figure out when we'll actually know what the spending is. So I didn't know if you had any thoughts on that. I think I think you're right to have it on your radar. You know, I have no additional thoughts other than what we've already sort of talked about, which is, you know, it's unclear to me whether the, the just the demand for these hospital services is going to come back in the summer or whether it's going to come back at all or whether it's going to come back at, you know, 50% what it was. So, I think that's obviously going to change the way that that you have historically looked at the claims and the claims lag over time. So, other than the habit on your radar, I mean, it's really, I think going to be hard to, to give you solid advice, maybe the insurance companies can do a better job. Yeah, I mean, I think this is going to be a tough rate review season this summer. We're not going to have the information that we need. So with rebates, I think this is more a comment. As since we are going to be moving into QHP rate setting and we're already in the midst of large group rates, rates, premiums for the next round. I think making sure that we remain in close contact about what you might be thinking in terms of rebates. Basically, we're going to need to factor that kind of information into our premium setting that we're going to be doing shortly. So that's the comment in terms of we do have that overlapping area that we're going to need to make sure we coordinate on. And then lastly, I just wanted to say to Maureen's comment around price gouging. I think that there are two other area, two other ways to, to keep track of that. One is I know the Attorney General's office has been thinking about and on top of looking at price gouging initiatives in all areas. But we also have rate setting authority. So that could be an area if there appears to be a problem that we could start to exercise our authority. Yeah, good point. And just, I'll just give you some clarity about the first comment that you made about the timing and rebates. And certainly, I think the department and the board obviously want to keep in close contact. I 100% agree with that. But if I were to give you my honest assessment from where we stand now, I mean, I think we're probably looking at plan year 2022 for all of this, all of the stuff that we just talked about being reconciled. I just don't envision us having clarity about where a number of these things will shake out until basically this time next year. So you know, again, we should stay in close contact, but I wouldn't anticipate our department being proactive in that regard until there was a very clear sense that we weren't going to have to, you know, you don't want to have volatility and pricing. You want it to be consistent. So, and I think that's to the benefit of consumers, both from a pricing standpoint, but also from a, you know, the solvency and the reliability of their health insurer as well. Thank you. That's all I have. Thanks for your presentation. Yes. Yeah, thank you. And I appreciated Robin's request for close communication with your office commissioner P check. I think that'll be really helpful. And I really thought your presentation was very clear and insightful. And I want to thank you for the swift and decisive action that your office did, you know, as this public health crisis came before us. I'm wondering my first question is are any of the temporary actions taken by your office. Are you envisioning any of them becoming permanent. So, COVID-19. Yeah, good question. So the, you know, the, the actions around. You know, most of our actions extend through the state of emergency. I'll just put it that way. So they're going to be here probably for a little while. You know, they're going to be in place for a while. The ones related to COVID obviously will fall off once the current pandemic is is we're through that. The, the, the point about telemedicine, you know, we expanded it to audio only. There is, you know, the reason I think it was not audio only to begin with is because there are concerns under HIPAA about ensuring that the doctor is actually talking to the patient like you and I can ensure that we're talking to each other here. So when you do audio only, you know, it does raise the specter of elderly or other vulnerable populations getting taken advantage of and sharing important personal information in a way they didn't intend to. So that is a concern longer term on the telemedicine, one component of the telemedicine that we've done on the 30 day supply. For example, another concern is the availability of pharmaceuticals. You don't want people hoarding medicine if it's not necessary. So I think we will look closely at each of these and see what their value is or relevancy is after the COVID pandemic is complete. I think I said that I think has the most problem as I sit here today, the one that probably would most likely maybe in a new form, but most likely continue would be the telemedicine emergency rules something around that because I do think that will continue to be of interest to Vermont's in terms of how they get medical attention in the future. Yeah, I think that's a really important line of, you know, inquiry as we get out of this. You know, we've heard a lot about people actually liking telemedicine having that access with their providers and to the degree that we're a rural state and transportation barriers are real. You know, this could be a huge silver lining in this public health crisis is increasing access to telemedicine. We need bandwidth. And that's something else that had to our agendas collectively as a state, but I think, you know, I would hope that some version of telemedicine would stay. My question is, I agree with you on the tremendous uncertainty and I've appreciated I've listened in on a lot of the press conferences, in which you've been very involved with some of the projections going forward. And, again, recognize that there's a lot of uncertainty as I'm trying to think about the predictions around the impact on private insurers of treatment of COVID-19 in particular and your data shows this. And hospitalization is where it's really expensive right 40 to 70 K, you know, back of the envelope calculations around treatment. But I'm wondering, you know, you've been involved in all these projections and seeing some of the evidence. It seems to me I don't have all the data in front of me but the older population is the one more likely to be hospitalized. They're the ones that are going to incur these hospitalization fees they're more likely to be under Medicare, I guess. I'm just wondering as we think going forward about the high cost of COVID-19 as an offset to the delayed care that the insurance providers are not, you know, incurring right now. Should we be thinking about who's most likely to be hospitalized and are they most likely to be insured by a private carrier versus Medicare. So I'm wondering what your thoughts on that. I think it's an insightful way of looking at the problem because, you know, not every, you know, if there were 29 people in the hospital last week, not all 29 of them are with one of the exchange plans, for example, or one of the plans that you'll be, that one of the insurers selling today that you'll hear from that could be other ways that those individuals are getting insurance. I do think it's important to think about that, certainly. We have seen, you're absolutely right, people that are between 60 and 70 and 70 and 80 and 80 plus are more susceptible to severe complications as a result of COVID-19 as are people with underlying medical conditions. So it is something to be mindful of that that very well could be the case. I will mention something else that is unique that we've experienced in Vermont that we weren't, we hadn't heard of in the national data or elsewhere, which is we expected to see a lot more hospitalizations, particularly as a result of our elderly population, but a lot, particularly as a result also of the outbreaks that had occurred in the nursing home facilities. But a lot of the individuals in the nursing home that ended up passing away never went to the hospital. They died in place due to instructions under that, under, to that effect. So that's something else just to keep in mind is, you know, we want to, we want to, there's a lot of different factors here, obviously, but you, you picked out an insightful one that we should be mindful of who is in the hospital, who is, who is requiring treatment, not just what the cost of that treatment is. So something, something on the modeling front, obviously we are really interested in for different reasons, but something we're keeping our eye on closely. Okay. Thank you. Anyone else from the board before I open it up to the public? If not, would anybody from the public wish to offer a comment on commissioner P checks testimony? Sure. Hi. Hi, Kevin and everybody else. This is Kathy Mahoney from the, from, from Ludlow Vermont at the moment. And I, I just have a comment and that is around the intriguing option of type of reimbursement, as you said, like a rebate Kevin for, you know, what auto insurances are doing, but I share Mike's hesitation about timing and the reason I do is because on the, on the clinical front, we don't really know what the medium and longer term consequences are of, of COVID-19. You know, I think we have to be careful of, of planning based on what we presently know, because it evolves so quickly. Even in the younger patients who are having this disease, many of them are really debilitated when they come out. Some may suffer some long term consequences. There's a number of case reports of things like that, people with clotting issues, strokes, amputations and things like that. So I think it's a good idea, but I agree that it's too early. And if we are going to talk about maybe some financial monies to be set aside, maybe that's, that's something that could be considered in the shorter term, but I think we have to wait a good six months plus to see how, how our patients do collectively. Okay. I don't think there was a question there. So other members of the public hearing none. I wish to thank you, Commissioner P check. I am somewhat discouraged by one statement that you made that hospitals in June might be able to do non elective and I know that everything has to be driven by the data. But as I talked to some hospitals in areas of the state that have no inpatient COVID remonters being treated, I would hope that the administration would be open to listening to plans put out through VAS or by individual hospitals that would protect people, but also give them the ability to get the type of preventative medicine that could save dollars to the system in the long run, such as colonoscopies and mammographies and, and those type of things. And the last thing we want to do is see cost skyrocket because people aren't getting adequate medical care for a prolonged period of time. So just I'll throw that and keep it in your ear. Yeah, no, excellent, excellent point. I mean, as you know, as well as the board knows early intervention results in better, better medical outcomes and almost every case and certainly better financial outcomes too. So certainly something the administration is open to and didn't mean to suggest that's the line in the sand just as an example of the timing that we might be dealing with. Super. Thank you, Commissioner. Thank you very much. Have a good meeting. Thank you. So at this time we're going to move to the three carriers and we're going to start with Blue Cross Blue Shield with Don George and Dr McIntosh and basically Don, is it just the two of you or others going to speak as well or It will just be myself and Dr McIntosh. Okay, great. And do you have control of the Skype meeting so that you can share your presentation. Actually, if Abigail is on the line, rather than risk a delay fumbling with the technology on my side, Abigail, if you could please bring up the Blue Cross presentation. I thought that worked well for commissioner P check. Of course. Thank you. Can everyone see that. It's loading still. Now we can. Can you see it's on. It's still loading for me. There we go. Thank you. Thank you, Abigail and Rutland must be better. Thank you to all the members of the Green Mac care board for having us here today and thank you to the more than 50 participants who have joined today. As mentioned, I'm Don George. I'm president CEO of Blue Cross Blue Shield of Vermont. I am joined today by my colleague Dr Kate McIntosh was a senior medical director in our integrated health area. I'm going to begin today by sharing an overview of our response. I'm excited about the approach that we take and some areas of particular focus for us. I'll be followed by Dr McIntosh in her sharing of some of the very specific programs and policy changes that we have made in response to the COVID-19 pandemic in Vermont. And then once Dr McIntosh concludes, I'll come back just for a moment to share some closing thoughts on the challenges unknowns in the road ahead for us. So Abigail, if you would, you can go to what is our slide to it's a Blue Cross Blue Shield guiding principles and at the beginning of the pandemic. At its onset, we set down the principles that would guide all of us at Blue Cross Blue Shield of Vermont. I'll just comment on some areas of focus. First and foremost, we focused on the safety and the security of Blue Cross Blue Shield employees. We always feel responsible for their health and well-being, but particularly in this crisis, we understood that keeping our employees healthy was an imperative so that we would be here. Our operations would be complete and in continuity so that we could continue to serve Vermonters who depend on us as the pandemic spread throughout Vermont. So all of our employees were home sourced in three waves over two weeks beginning in the middle of March. We also at the same time we were home sourcing we communicated extensively with members and customers to ensure that they were constantly apprised of news. So that's what they needed to know relative to the pandemic and also a price of important information about coverage changes in program flexibility changes that we're offering to customers. And that communication is ongoing. One of the strong principled approaches that we have taken as a commitment to support providers and public health to strengthen delivery capacity. The moment Dr. McIntosh is going to share our telehealth program that we brought up very quickly at the onset of the pandemic, we felt that this achieved a number of objectives we are committed to. Certainly with supporting physicians and community providers to maintain their cash flow or at least part of it during this period of time, they're able to maintain their patient census. Well, it's also supporting our members to maintain continuity of care and contact with their physicians and community providers during a very critical time. Finally, I just comment relative to our principles that we have been committed to the very principle that in crisis, the speed with which we make actions is as important as the quality and the meaning of those actions themselves. So that to say above all, we have really endeavored to respond as quickly as we possibly can to the program changes we've made. We can go to the next slide Abigail. So we're here today, Dr. McIntosh and myself and appreciate the opportunity to share some specifics about Blue Cross Blue Shield of Vermont's response. But we feel that we are part of an overall state response in which all of the individual contributors like ourselves need to be in concert with others and the state to support the overall strategy and response. So that's why we have supported the public health strategy in Vermont. We've done that by aligning and collaborating with health care providers in Vermont. And with many areas of state government, including the Department of Health, the Department of Vermont Health Access and most certainly the Department of Financial Regulation. I certainly would agree with Commissioner Pechek's representation that the stakeholder meetings that his department has coordinated have been highly collaborative, very thoughtful process. I think it has served Vermont's well during this time. But within this larger framework, Blue Cross had responded with numerous program and policy changes to support members, customers, the public health and also providers. And in a moment again, Dr. McIntosh will provide some specifics on those programs. We can go to the next slide, Abigail. So I thought by way of introduction, I also would give you an image of what I refer to as Blue Cross Blue Shield of Vermont's rapid response teams. We formed a pandemic preparation team at the onset of the pandemic. It was led by Dr. McIntosh, who you'll hear from in a moment. This was the team that focused on all of our pandemic response objectives and the program and policy changes that we have made. We also were served well by our business continuity team. This is an existing team that every year creates and responds to mock exercises of emergencies in which they need to ensure the continuity of operations and services. And certainly this was no mock exercise and they performed very well. In the first two weeks of our response through these two teams, Blue Cross has adapted our technology to enable more than 400 employees to work from home. We've also ensured the continuity of our core operations. As I alluded to, we've changed numerous programs and policies to support members and providers. I spoke also of the importance, critical importance of communications during this period of time. On behalf of literally thousands of individual customers throughout the state and more than 200,000 Vermont members, we've engaged in an extensive communication campaign to keep our members and providers constantly apprised of what Blue Cross Blue Shield is doing. Our flexible approach to premium payments that is on this slide has been among those many changes that we communicated to providers. We believe that this program recognizes that during a really difficult time, a down economy as well as a health care crisis for some of our customers, we acknowledge that they're going to find it difficult to stay on their regular premium payment schedule. So for our large customers and small businesses, what we refer to as our group customers, we are waiving all the requirements that their employees be actively employed in order to remain under group coverage. We're providing them flexibility and frankly we're encouraging them, even though they may be in a circumstance because of social distancing and the health care, the economy as it exists today. They may be in a position of having to furlough employees, certainly with the intent of bringing them back once we are through the crisis and the economy picks back up. We're encouraging them to maintain those employees on the health insurance to the extent that they're able to do that. And we're also providing our small businesses and individual purchasers with the flexibility to make some, if not all, of their premium payments or an extension of time in order to make the premium payments. And as I speak to you here today, we're not experiencing any reduction in our membership, so we're hopeful that these things are helping. And Abigail, we can go to the next slide. We approach this crisis in Vermont from two different perspectives. We're in the midst of both a health care and an economic crisis, and Blue Cross with Shield of Vermont and our customers are being impacted by both. So Blue Cross with Shield of Vermont as a single state non-profit blue plant serving only Vermonters is committed to the most expansive role that we can play to support Vermont's response to COVID-19. Commissioner Peecheck did a very nice job of explaining the need for member reserves and what the reserve levels approximately are for the insurers, including Blue Cross. I would just say we have member reserves to protect Blue Cross and our customers and providers from the risk of unpaid claims and potential insolvency. And responding to pandemics like COVID-19, it's just one of the reasons that we have illustrated over the last several years of why it's important and why frankly we insist on maintaining adequate reserves to protect members and providers. And while we are by no means over-reserved, we do feel, we would agree with Commissioner Peecheck, we do feel prepared to see Vermonters through this crisis. Nevertheless, we're mindful of both the magnitude of the potential impact and the duration of both the health care crisis and the economic downturn. With that, I would say that we are also mindful that there is absolutely nothing in our history which we can measure how this crisis will test us or test our financial resolve. And I would imagine that the same could be said on behalf or by every provider and stakeholder in the Vermont health care system. So Abigail, you can change the slide again, thank you. And so that is the introduction. I'm going to turn this over to Dr. Mackintosh and I'll be back with you in a few minutes. Thank you very much. I want to make sure, am I coming through clearly? I can hear you fine. Okay, perfect. Thank you very much. Could I have the next slide please? So thank you for the opportunity to tell you a little bit about what we're doing at Blue Cross to try to help. We tried to move very quickly when this became evident that it was coming our way. And I think it's fair to say that under the guidance of DFR and in concert with the other plans in Vermont, including Medicaid and the other private insurers, Vermont has rolled out one of the most generous telehealth programs that is available around the country and very aggressively. And our goal was to be able to allow providers to replace office visits with telehealth. The hope of this was that we would support providers to maintain their cash flow and their patient census. And there have been dramatic drops in the number of office visits around the state. But we have seen a high variability in the actual drops among our different types of provider. But we have providers who have successfully made an impressive switch to telehealth and are able to maintain their capacity. Not at 100%, but they're doing okay. We have others who are not. So I think we have to be sensitive that there's a wide variation across providers. We wanted to support patients with continuity of care. And we also wanted to protect providers and patients from in-person contact. And this is really important because we wanted to be able to preserve the PPE and the other equipment for the hospitals where it really needed to be used. We also wanted to keep people out of the emergency room and out of urgent care if possible so that we could preserve the emergency room for those waves. And the thing about this telehealth approach is that because it is flexible, it will serve us well should we get a second or even a third wave of COVID-19. I think that the consensus is pretty clear across physicians that we are going to get additional waves of this. We don't know how bad they're going to be, but we know that they will come. The question is not if the question is when. In addition, because of the connectivity issues that Dr. Holmes mentioned, we do have big issues with connectivity around the state. And we knew that would be a barrier to telemedicine. So what we did was we turned on code so that audio only telephone could be used rather than audio visual telemedicine for some types of visits. This is not without risks in terms of quality, but we felt that it was important to be able to do this increased access. And finally, we turned on store and forward payment in our permanent telemedicine policy. This is not emergency turn on that. We turned it on across the board. It's ready to go. Could I have the next slide, please? We also expanded our existing telemedicine policy, as I said, to include outpatient visits that went to telephone only. We expanded existing mental health counseling options, very specifically adding crisis intervention, intensive outpatient treatment, and all of the existing mental health counseling options, which were already very expansive. We added preventive care and behavioral health screenings, including new patients to our telemedicine policy. We also permanently added some elements of physical therapy, occupational therapy, and speech therapy to our permanent telemedicine policy because we also believe that the future of telemedicine is that it is really here to stay. But we also then expanded additional measures for physical therapists, occupational therapists, and speech therapists. Could I have the next slide, please? All of these temporary and permanent changes will be looked at at the end of the emergency period. We do not plan to remove anything from our permanent policy, but we may find that there are elements of our temporary policy that we would like to move on to the permanent policy and maintain. We also instituted a telephone triage payment at zero cost share to members to try to support providers for managing a dramatic increase in the number of calls that they're receiving to their offices. Previously, this has not been a billable code. We did it institute this emergency policy to try to support the need for nurses and other triage individuals to be answering the phones. We also added limited applied behavioral analysis, and we expanded codes to meet the other needs of autistic children because one of the problems of schools closing is the kids with special needs are not receiving some of the services that they need. So to be able to provide those services over the phone, some of them we have, we added to the permanent policy, some of them we added to the emergency policy. We also to our permanent policy added lactation consultation over the phone. And we also authorized the home health agencies to perform some limited follow up that they felt was medically capable or medically appropriate to have allowed them to do it either over phone or telemedicine. And we're continuing to look at what our other areas are that we might need to expand out to. Could I have the next slide, please? So this gives you some sense of the evolving expansion and I will tell you this slide, I did this slide two weeks ago and I can update these numbers for you. So these are, this is the difference. The little tiny blue dots are what are the amount of telemedicine that we had March and April of 2017. And the red bars are telehealth claims visits and dollars paid in 2020. So 2019 to 2020, there is a dramatic change in the amount of telehealth that is happening. And these numbers have been revised up yet again. As of 427, we have had a total of 36,698 claims of which 18,400 were mental health, 16,700 were office visits. And we have paid in total just in March and April of 2020 so far $3.3 million in telehealth claims. So our providers have pivoted rapidly. It is dramatic the work that they have done and they are taking advantage of this to try to help both of both their practices and their patients, whether this storm. Next slide, please. So we have also waived member cost share in our benefit expansion for as, as Mike, as Mr. Pichac talked about all COVID-19 testing related to office visits, providers via telemedicine, urgent care or ER. So not just the testing, but the office visit COVID-19 inpatient and acute outpatient treatment, which is both complicated and costly, but we are working very hard on implementing that nonurgent ambulance transport for COVID-19 patients who require isolation. This is very important when you leave the hospital with COVID-19. You can't necessarily get in the car with people who aren't infected. So it's important to be able to transport people from one place to the other in a way that allows individuals to stay isolated. We have also waived cost share for acute telemedicine visits to the vendor, especially at the request of some of our ASOs. We've talked about the telephone triage and we've complied with all of the federal state bullets and the rules and all the other changes that have come through to make sure that we are trying to meet the needs of our members in this time. Can I have the next slide, please? And so the goal of all of these temporary waivers has been to try to facilitate necessary patient care, ease the administration for providers. We've allowed the early prescription refills that DFR mentioned, allowing longer supplies of essential medicines. We've tried to manage drug shortages. We've tried to manage off-label prescribing and hoarding, and we've also tried to facilitate member access to grand and specialty pharmaceuticals where possible. We have also waived some prior authorizations and prior notifications, and we are extending imaging authorizations out 180 days. And also we are evaluating procedures that were deferred as a result of the epidemic, and we will be pushing those out as well so that members are not finding that their authorizations have expired. We have been able to, because as we've talked about, there have been fewer non-essential procedures, we are not finding that our members are as highly impacted by these as we thought they might be. So that's a good thing, but we're waiting to see what happens as the hospitals begin to bring services back online hopefully soon. Could I have the next slide, please? And finally, provider support. We are very concerned about financial stability. We have devised a hospital advanced payment program and are in active conversation with the hospitals. We have also devised an independent and community provider revenue stabilization program and are working with our independent and community providers as they need to try to help them stabilize the revenue as we go through this. We have also been in close contact with OneCare to help them revise their programs. Providers are busy. They have other things on their mind. A lot of these programs are not going to be in 2020 what we thought they were going to be. So we have restructured the 2020 quality program to remove provider financial commitment and OneCare is funneling those funds directly to practices. We're working to restructure our risk agreement to adjust for the COVID impact and we made a prospective payment program available to all the hospitals in the OneCare network. We are also continuing our blueprint payments and we have suspended any recoveries that might have been in play. Next slide, please. Finally, we have discontinued these routine audits in accordance with the DFR bulletin suspended pharmacy audits. We are, however, watching closely for price gouging and for fraud because this is an area of big concern, especially with the COVID-19 testing and a lot of the suspension of in-network and out-of-network. There are areas of risk there, so we're trying to keep a close eye on that. We have streamlined our credentialing process to facilitate payments, to traveling providers and to also work with people who are working across state lines. And then we have done a series of education sessions with our new and revised telemedicine and telephone policies, speaking to by-state through VPQHC and VCHIP and also trying to have robust communications on the provider portal and with provider association so that everyone is up to date on the changes because things are changing very quickly. And then we have also created rapid reference specialty specific bulletins to help individual groups figure out what they can and cannot do on telemedicine and how to build that. And we are continuing to do rapid claims processing and payments. Next slide, please. And finally, we have been working with Diva and with the health department to try to support a cohesive response around surveillance and testing. We want to support whatever it is that they have that they choose to do and to try to make sure that we bring our cooperation fully to that. We also are encouraging our self-funded employers to adopt DFR policy and regulatory changes with regard to COVID-19 health coverage. And we are really pleased that we've had wide buy-in of the DFR policies. We are also providing and extending our COVID-19 special enrollment period for the uninsured and providing and analyzing these COVID-19 data and results and giving those to DFR and working with Diva to see, we are all working in concert. Next slide, please. So I will turn it back over to Don George. Okay. Thank you, Dr. McIntosh and Abigail, you can go to what is slide 17. So we've heard a lot about how the assumptions about the road ahead for us continues just to be the subject of debate and speculation. And when it comes to trying to rely on financial impact assumptions and projections, I think that Dr. Anthony Fauci said it best. When Dr. Fauci stated, and I'm quoting him now, I just don't think we really need to make a projection when it's such a moving target that you could so easily be wrong. I really do agree with Dr. Fauci that we can do projections, but the future is going to be very difficult to project, probably right out through to 2022. But I would say that we do see some areas of uncertainty and new costs that are emerging. I have listed them here under significant claims on uncertainty and new costs. And I'll just comment on each of them lightly. Certainly, we heard from Commissioner P check about temporary cancellation and non essential services, heard from chair mullin about how hospitals, what their experiences now, certainly blue cross shield is now even with a claims lag beginning to experience this. I do know there's interest from some of the board members about what blue crosses experiences so I came prepared to share it today. We are actually have developed a model. It smooths out really what are the normal ups and downs or fluctuations that we would see in a week to week or even month to month claims submission and have created a model in which we feel like we're able to do that by at least a range of a decline in claims that is attributable to cobit 19. So I'll give it to you in three categories for Vermont facilities Vermont hospitals. We are experiencing this is that the last week, a 40 to 60% reduction and what we normally would see and we that we would attribute to cobit 19 from professional providers in Vermont. We're experiencing a 20% to 33% reduction that we would attribute to cobit 19 less than the Vermont hospitals. And so we would attribute at least some of that to are the early intervention with the telehealth program. For prescription drugs, actually a quite different experience. We're seeing a 7% to 17% increase in scripts being written that we have attributed to cobit 19 and we would attribute this quite likely to the change of policy that we have allowing up to 180 day supply. So the second bullet that I've listed here, of course is cobit 19 diagnosis and treatment and for what unknown duration. Certainly we've heard a lot from commissioner paycheck about this issue. Really, the unknowns become how much and what type of care will need to be provided. What will be the infection rate. We did have a good question of commissioner paycheck about, you know, certainly those are the most vulnerable in our population are older. They would not tend to be in a commercial population. By the same token, we're receiving reports of those who are in their 30s, 40s and 50s. Contracting cobit 19 and not being quite as vulnerable as our older population they're able to recover. But we are seeing some very long intensive care unit hospital stays related to those people who are in middle age. But contract the virus and are therefore recovering, but recovering at the expense of a very long ICU stay. This next bullet point about a portion of delay care returning is one that I am concerned about and I really think bears watching and that is we have a some cancellation and delay of non essential services. So we think a portion, not all, but some of that delayed care will return. But also in the aftermath of cobit 19, you know, will we experience a decline, a general decline in the health status of at least I would say the blue cross blue shield members that's related to delayed care and the isolation of social distancing. So I think the question here really becomes, you know, how much and what type of care is going to be delayed and of course for how long, but also at what consequence. So there is this interplay between the delay of care and ultimately the health status that we emerge from cobit 19 with, and we could be left with a deteriorate health status that would exert an overlay onto our health care system a cost which we are currently not experiencing today. Certainly the future cobit 19 treatments and other costs remains an unknown. And then, of course, there's generally a month of health care and public health professionals. There is acceptance that we will have a second wave or perhaps even a third wave of cobit 19 in the fall or even in the spring next year or even the potential that this could become endemic. So we need to be prepared for that. In consideration of this all, I would say that we believe that blue cross that claims uncertainty will persist for the weeks and the months ahead. And the uncertainty will likely come in waves and in waves of unknown duration. Certainly it will be difficult to get a picture of what these true costs are going to be until beyond 2021. All of that said, in the end there has been discussion today in questions about insurers receiving a financial windfall. We're certainly not operating from the perspective that there will be winners or losers, or that somehow we will end up with a windfall from this. But to be sure, this is not about winners and losers. So in the end, if blue cross blue shield does receive a financial windfall, as always, this money will be used to mitigate future rate increases. I think that that is a well established, well known, well worn path for blue cross blue shield or Vermont. So please be assured. Abigail, you can move to the final slide. Thank you. So I just wanted to touch here on what the future holds for us in terms of our current and reformed health care system. And while the duration of both this health care and economic crisis is unknown, I do think it's important for all of us to learn as we go through this experience of the really dire circumstances in front of us. And it gets important even today to reflect on what areas of our current response will become permanent changes. I appreciate the questions that have been asked about that. So you heard Dr. McIntosh say that from Blue Cross's perspective, we certainly think some aspects of telehealth will continue in the future. We have seen all of our health care providers who are struggling with the lack of revenue that has occurred. I hope that this crisis of nothing else will give us the opportunity to put fee for service reimbursement in our rear view mirror of health care reform and adopt global payments that will provide a consistent stream of revenue during normal times and during times of crisis for our health care providers. And then finally, I would say that we should be thinking now even about how do we carry forward all of this learning to reshape the health care system to not only be ready for the next pandemic, but also provide for monitors the health care that they need and deserve in that affordable cost. So thank you all for listening and Dr. McIntosh and I would be happy to take questions. Great. Thank you, John. Member Usper. I'm good. It was a really clear presentation. I think we're, you know, it really is kind of a wait and see what happens and we could all kind of predict what we hope will happen, but I think it's something we will wait and see. And I agree that in the past, the things are given back to the rate payers or adjustments made if there were big additions to what would be the surplus. So. Member Callum. One question. I mean, I have the same observation that Marine does and most everyone does is we're all going to have to remain quite agile in the months and years ahead as we kind of pull out of this one insight that I would ask of Don and his team. Is, are there any insights that you have in terms of, of during this pandemic, how you've engaged with independent providers and specialists versus those who are aligned with hospitals? Is it, you know, has it been smooth on both fronts or are there distinct differences between the two? Well, I would say that we generally do not approach physicians, whether they be employed by facilities or independent differently. We are certainly accessible to both. I do know that Dr. McIntosh did a great deal about reach working with community physicians on, you know, what specific codes they needed and the development of the telehealth program. We have developed, as Dr. McIntosh said, we've worked with community providers to develop a specific claims advanced program support system for them and we are talking to a number of them about accessing that. So I would also defer Dr. McIntosh to you as to whether or not you have experiences differences in on this question. I think that there is no question at this time that into the providers are feeling very vulnerable. And I say that because I ran a practice for 16 years before I came across and, and I am in really pre-contact with the pediatrics at my area. But also bystand some of the other larger groups. And I think that there's a vulnerability, especially among dependent mental health providers, and it also independent practices because they have necessarily the reserves and the cushions. We have done a lot of extrication and support of explaining telehealth and how to under, you know, how to take that, how to make it work, practice, and then also creativity. The pediatricians have been so rich because they need to vaccinate kids in a time when they're scared and practices are uncertain. And they have been amazed in their ability to step up and really come up with creative solutions to work with, to try to figure out a vaccine. And how to see if you really do need to be seen and per se possible at this time. And so I'm incredibly impressed by the activity and the willingness to try out things that we might not have considered that I'm seeing in the independent writers. I do think there is that additional sense of insecurity as a result of not having a large situation at your back. Thank you. Member lunch. Thank you. I don't really have any questions I felt like the data provided really answered a lot of the questions that I was prepared to ask about. Just one comment on the telehealth. Expansion and kind of where do we go from here is I do hope that when you are thinking about down the road changes to be made permanent versus temporary that you keep in mind the broadband issues in terms of the more rural areas of our state and how phone access. Certainly there are many types of services that it would not be appropriate for. But where clinically appropriate having that availability for low income people in rural areas in particular will really be an access expansion that would be needed quite frankly with or without COVID-19. So just a comment that I hope you keep that population in particular in mind when you're thinking through what makes sense to continue. That's such a good point. We will absolutely keep you out of mind. Thank you. Okay member halls. Great. Thank you. So I want to say first of all very clear presentation and I appreciated all of the crossbow shields. Responsiveness on so many levels from delivery reformed, you know, in terms of expanding telehealth to payment adjustments in terms of advanced payment to hospitals are really helpful and I agreed. And I think that the permanent changes to telehealth and the importance of fixed payments and alternative payment model. So hoping this opens up a new dialogue as we come out of this for what our future looks like and I'm enthusiastic to hear that, you know, in some ways some of the learnings that we're seeing you're also agreeing with my quick question is last week I was listening to Adish Jamal's testimony to the joint Senate Health and House Health committees. And what she testified to was that she saw there was an increase in Medicaid enrollment in March, April of about 5,000 households and a very small increase in about 237 households on the QHP through the expanded enrollment period. And I'm wondering if you could just update us on your enrollment changes, what you're seeing. Are you seeing a loss of members moving towards Medicaid from your subscriber list? Good question. Thank you. So on the commercial side we have been tracking membership by the week and reporting it since the onset of the pandemic. And we are down less than 500 members out of more than 200,000. So these could have been large group customers who furloughed people and chose not to keep them on their health insurance. We're seeing very little decline in the QHP population. I would say we're seeing relatively little uptake in the open enrollment period, which seems unfortunate. My understanding is that there is about 250 overall. So, you know, I think that we are our proportional share within that. So, no, we're not seeing membership declines right through to this week. Okay, great. Thank you. Okay, at this time I'm going to open it up to the public for any public comment. Hearing none, I wish to thank Dr. McIntosh and Don for an excellent presentation. So, we're going to now move on to MVP with Dr. Kim Kilby and Richard Oderizzi. And do you wish to control the slides or do you wish to continue in this format with Abadiel controlling them? So, we don't have a formal deck. I did provide a web address in your agenda that you can refer to for the details and I'll just be speaking as well as Rich. Okay, great. So, thank you. I wanted to just introduce myself. Dr. Kim Kilby. I'm a family and preventive medicine physician. I completed my family medicine residency at UVM. And currently I serve as the senior leader for the regional medical director team at MVP in my coverage area is Capital District, New York and Vermont. I also just want to mention that about 10 years ago I led the New York State Department of Health Epi and surveillance response to H1N1 because I was the director of Communicable Disease Control. So, this all feels very familiar and certainly happy to be here and give you an update. And thank you for the opportunity to share with the Green Mountain Care Board the efforts MVP has made in our clinical response to COVID-19. After my portion, I will turn the stage over to Rich Oderizzi to be able to give the financial update. MVP Healthcare is a regional health plan with membership of 700,000 across New York State and Vermont with 39,000 members in Vermont. As many of you are aware, New York State was one of the earliest areas affected and as such we feel at MVP we have been aggressive and extremely proactive in our response to the pandemic from its earliest days, which has led us to be quite well positioned for the decisions that later came from Vermont DFR as much of what was ultimately placed into regulation in Vermont we had already implemented across our network. Although I will share in detail the clinical changes we have made, I also want to bring your attention to the website which is in your agenda and gives a detailed summary of all the changes we have made in response to COVID-19 to date that specifically for providers and gives that detailed coding guidance. That's part of the reason I didn't want to codify things in slides is because it continues to evolve and we want to make sure people have the most accurate information at all times. The MVP website also contains detailed information for our members which we have been posting regular updates to as well as posts on social media and that website is www.MVPHealthCare.com slash COVID-19. And we certainly want to make sure that our members have access to the information we are promulgating. Since the beginning of our pandemic response, the MVP approach has been threefold. The first is to maintain seamless access to all needed care for our members. The second is to support our business continuity, safety of our employees while also maintaining an optimal level of service and access to health insurance functions for our members and providers. And the third is to support providers in their ability to provide care to their patients, our members. I'm pleased to highlight some of these recent changes for you. One of the earliest adjustments we made is to ensure that COVID-19 screening and testing would be free for patients by waiving any out-of-pocket costs. The cost share was waived also for emergency room visits or visits to an in-network health care provider for the purpose of getting or for determining if testing was needed or getting tested. As well as drive-through specimen collection sites which were fairly prevalent in New York state. As well, MVP made the business decision very early on to waive cost share for all telemedicine services regardless of the telemedicine service connection to COVID evaluation. We supported primary care physicians and other physicians and providers in our network to be able to provide their own telemedicine services. Those services are also covered in full. Telephone-only visits were allowed initially for mental health providers given the nature of the care they provide. And in addition, effective March 13, 2020 in Vermont physical health providers were also included for coverage of the telephone or audio-only visits. Medicare and CMS continue to require the use of specific telephone codes for Medicare members so that stays in effect for us, for our Medicare membership. We have communicated with Vermont doctors and providers about the relaxation of telehealth restrictions including that during the state of emergency existing patient relationship is not required. HIPAA remains paramount but non-HIPAA compliant non-public-facing platforms such as Apple FaceTime and others are allowed. The rates are being paid as the same as in-person visits based on the provider's agreement with MVP. Services can be provided at any state as long as the member is active and provider is participating with MVP. Physical therapists, occupational therapists, speech therapists and certified athletic trainers may render telemedicine services to MVP commercial members. We also quickly stood up a virtual emergency room telemedicine service called MyERNow. It is powered by United Concierge Medicine that allows MVP members to connect 24-7 with trained emergency medicine providers from the comfort of their home. We have been directing our members who have symptoms of COVID-19 to use this service first to help ensure people can remain safely in their home as well as to prevent the unnecessary surge on the Vermont healthcare system. We continue, and all of that is at no cost share as well. We continue to provide MyVisitNow, which is a telemedicine platform we've had for quite some time, to our membership. And that provides access to a national network, the online care group for urgent care services, behavioral health and psychiatric services, nutrition and lactation consultation needs. We have been encouraging that avenue for our members at low risk for COVID and who have other urgent care type of needs, again, to try to reduce the burden and the surge on the healthcare system. Regarding treatment for COVID-19, effective March 13, 2020 through May 31, 2020, MVP will waive the member cost share for the treatment of COVID-19 at any site of service, including inpatient hospitalizations and emergency room visits. Regarding prior authorization, effective for 90 days that began on March 20, we suspended prior authorization requirements for all lines of business for inpatient surgery, inpatient admissions to any hospital. Post-acute services after discharge from any inpatient stay to skilled nursing and rehabilitation centers. All radiation therapy and high-tech radiology, including MRIs, MRIs, C-tanks, nuclear cardiology and PET scans. And also all of the interventional, musculoskeletal surgical prior off that was previously being done. MVP also modified the admission requirements for inpatient mental health. Mental health residential, inpatient substance use detoxification, inpatient substance use rehabilitation and substance use residential for 90 days. And we had also previously removed partial hospitalization and continued day treatment from our prior authorization process. That is permanent and that was effective March 17. Effective March 13 ambulance transport related to COVID will be paid at no cost share for Vermont commercial members. Related to pharmacy MVP members in a commercial plan can obtain an early refill of at least a 30-day supply of maintenance medications at an in-network pharmacy. If benefit allows, the medications that are taken on a regular basis are also available by mail order and we've been strongly encouraging that. As well for controlled substances and specialty medications, our members' needs are being met on a case-by-case basis to support whatever ongoing need they may have. We also extended existing medication prior authorizations that we had in the system for an additional 60 days. Lastly, I would like the Green Mountain Care Board to be aware that MVP began a member outreach campaign on March 26. Our care management, health promotion and other MVP nurse teams were trained on psychological first aid response and commenced outreach calls targeting populations most at risk, which included all of our Medicare membership, all of our members deemed medically fragile, anyone utilizing adult day health services, anyone receiving private duty nursing or home care within the last six months, anyone with the use of a ventilator, trach or home oxygen therapy, and all of our members in our transplant program. We are also now added to that list outreach to known positive COVID cases. That resulted in a list of greater than 60,000 members that met that criteria and the calls continue and have helped to determine and resolve unmet needs among our membership. In conclusion, with the federal and state regulatory changes continuing to come, we would like to make sure that everyone is referred to the website as that's the source of the most updated information on coverage, status and coding, and that's the MVPHealthcare.com slash providers slash COVID-19. I will now turn MVP's presentation over to Rich Oderizzi for the financial updates. Thank you, Dr. Kilby. So MVP's been really on the front lines here since middle of February with the outbreaks in New Rochelle, New York. We have a large population down there, so we've really been thinking about this and planning for this for a few months now. We quickly moved to a work from home that's to help our members and our providers by us not having to shut down our offices and disrupt our performance to those members. Currently, we're at about 95 to 97% work from home. We have about 1,800 employees overall based in Vermont and New York, and over 1,700 of those are working from home at this point. We'll continue to work from home as we continue to help flatten the curve. As far as items directly impacting members, we work directly with Vermont and relaxed our grace period rules. We're up to a minimum of 60 days of grace period for all groups and individuals. We held off on any terminations from March 31st that were due, and in fact had only one termination for one very small group that owed for January, February, and March. And that termination didn't happen until last week after continuous outreach with the group. We continue to have major outreach with all of our groups, small groups, and are working with the state of Vermont for helping outreach to individuals to ensure that everybody has an opportunity to figure out how to make a payment or extend a payment. The other thing that we did with our groups was to open it up to allow them alternative payment methodologies, including credit cards. MVP is fully absorbing the credit card costs if that is the way that a group can pay. From a claims perspective, our claims operation teams have been working diligently to bring down any claims inventory we have. We actually had an overtime bonus program in the middle of March where we had employees work Saturday and Sundays to get all of our claims inventory down. We had a 35% reduction in claims, daily claims averages brought down by about 35% that allowed us to speed up payments to our providers and our facilities. Currently, all clean claims that come in don't have to be worked by a claims representative. Our payment is roughly a five to six day average. And we've also had major outreach to providers to let them know that we have electronic payment processes through one of our national vendors that allows them to have an EFT payment and money put directly into their bank accounts rather than having a check sent to them. That's allowing them to get money into their bank accounts two to five days earlier than normal. And finally, we really helped work closely on the full outreach to all of the members within Vermont, really trying to be as flexible as possible and understand whether they've hopefully been able to get a PPP loan for small businesses and as flexible as possible in us with with premiums. As far as financial impacts, we've had several different areas just quickly go to them and this is very similar to to what you just heard from from the blues I think our populations are very similar. We did see a spike in pharmacy in the month of March. That was due to those early scripts that were people that were able to renew and we have seen a major increase in the 90 day supply, which we haven't encouraging the impacts to the cost share for COVID had we have seen those as an increase. As mentioned earlier by Mr P check, we have had seen impacts on our financials investments, although there has been a rebound in April. We have a very conservative policy on investments but certainly have seen some impacts there. We have seen impacts negatively on the use of credit card so so those groups that we're not able to pay cash but we're able to pay based on a credit card. We have taken taken those and we're we're paying the full cost of that credit card usage. The other impacts that we're looking at a negative impact is is the grace periods of premiums. We have seen a dramatic slowdown in cash coming in the door for payment of premiums. Anywares from 20 to 25% decrease in payments, mostly over the last two and a half weeks. We're monitoring that on a daily basis. On a positive side. Yes, we are seeing that the slowdown pretty pretty similar to to blues of cases claims coming in the door, as well as payments to the providers going going out anywares from a 20 to 25% decrease in total dollars out the door. That's matching up with with our premiums which are deferred until June in many cases. That's that's our biggest concern right now on a negative impact side. In addition to the unknowns of how much the COVID is actually going to cost and what the future costs of COVID is going to be is the potential for the premiums from the small groups that are not going to be able to survive and not going to be able to get the federal loans that they desperately need and may ultimately go out of business and the membership may have to be decreased. Like the blues, we're seeing very little membership reduction at this point in time. We have seen a slight tick up in the open enrollment period for individuals, but it's really too early to tell what the membership impact is going to be. I really have a fear that May and June is going to be telling tale for the membership in which which groups are able to survive this. Hopefully what's a short term business shutdown, but it could go on longer. The other item that we wanted to mention is we we also are part of in conjunction with one care where where if there is savings over the course of 2020 one care will get their portion of that that cost savings return back to them. And that's that's that's what we had folks from our perspective. Thank you, Dr. Kilby again for for your comments. We've been at this what feels like a very long time. I'm home for all of us is is been a challenge. I felt like I've gone to work every day for the last 35 years and that never had a day where I work from home so having to learn new new tricks is a challenge but our employees are very much up to the task of supporting all of our Vermont members and all of our providers which are just as important. With with that, Mr. Mullins I can turn it back over to you. When you figure out how to keep ourselves away from the refrigerator. Could you look the rest of us know. Yeah, I wish I knew that one. Thank you for the presentation. Board members Maureen. Just thank you very much for the presentation this really has been very informative to let us all know what's going on and how you are handling it so I don't have any questions. I think you know time was going to tell what's going to happen with all this but thank you very much. Thank you for the presentation. He'll be near the end of your presentation you, I think said that you had a kind of an affirmative outreach program to all of your membership that you thought was vulnerable, basically kind of a check in to see how they were doing. And so I'm wondering what how many people in Vermont or do you know how many people in your Vermont portfolio, you know that you were in touch with and what what did you learn learn from those folks. I will definitely follow up on that I don't have Vermont specific data we are we are collecting and tracking the engagement and the outcome of those calls and any needs so I will certainly find out if there's anything that's standing out for Vermont and we'll say we have a fairly large Medicaid membership so obviously in New York that that tends to overlap with the types of criteria that I named. However, obviously our Medicare membership in Vermont is there as well so I will follow up on that. Thank you. Okay, Robin. I was curious to know if you're seeing your whether you're seeing sort of across both states similar trends if you're breaking that down between Vermont and New York. In particular, you had talked about the 20 to 25% slow down in premium payments, due to the challenges for small employers I'm wondering if that's similar in both New York and Vermont or if then, you know, New York is really skewing that percentage from our perspective. Yeah, that's a great question we don't have it broken down that way yet we're actually developing additional reports now to be able to break that down I do not have a breakdown of that at this point. Thank you. And can you remind me what your Medicare membership is in Vermont. Yeah, that's okay. 38 to 3900 members, almost just under 4000. Great. I think that's all the, the will I guess my one other question is I don't recall if you have a significant self-insured population in Vermont or not. We have a self-insured population I don't I'll be honest with you. It's it's a handful of groups. I don't know the total number of members of those ASO. Great. So in general over both states I'm curious to know if you're seeing some of the self-insured employers adopting some of the same policy changes that states have been requiring and the insured groups to. Yeah, Dr. Kilby, do you want to take first crack at that. Sure. I think certainly I do clinical support for the sales team in the ASO groups and from very early on I said we need to be strongly advocating for the same level of coverage as much as possible that these employer groups do adopt what is being recommended. First, just to avoid member confusion and provider confusion because it can get very, very muddy very quickly. So we have certainly gone out with that message. I think from a regulatory standpoint we have to allow them to, to make that choice. And we have to go through a process, but we've seen very little non-adoption and I, we can follow up on Vermont ASO groups as in their level of non-adoption, but it any thing that I've heard of has been related to employer groups in New York state. Okay. Thank you. That's all the time I have. Thanks so much for the presentation. Great. Thank you. And thank you again for the presentation. Really informative, really helpful. Appreciate the responsiveness of MDP. I just have a quick follow-up question from Mr. Oderisi, which is around the breakout. I think this is somewhat around Robin's question about breaking out Vermont. But I'm wondering if you can further break out from Blue Cross Blue Shield we heard that the medical claims were down about 40 to 60 percent for the hospitals and 20 to 33 percent for professional services. And I, you may not have that data with you now. And I totally understand that if it's possible to follow up with us for Vermont only, the breakdown between hospital and professional services and what you're seeing in your claims experience. Yes. We'll have to follow up with that. I, that I do not have here, but we'll follow up with our operations departments to get, to get a breakdown. Absolutely. Great. Thank you. No problem. So at this time, we're going to open it up to the public for any public comment about MVP's presentation. Is there any member of the public who wishes to offer a comment? Hi, this is Mort Wasserman. I have a question for Dr. Kilby. Go ahead, Mort. You're offering a couple of telehealth services to your members that don't actually go through their primary care practitioners. How do you assure a continuity of care in those instances? So, we have a couple of mechanisms in which we're assuring that one thing I would point out is that the services that predominate in those two virtual environments that were, one of them was previously part of our portfolio and the other one was recently added are for urgent care and or emergency room needs. And so those would function just like you would if you walked into an emergency room or an urgent care center and that you would receive your services. And then that communication would be provided to your primary care physician if you in enrollment stated who your primary care physician is and that you would like that information communicated. So very similarly, the same thing has happened in the virtual environments. And then also for the virtual ER, I guess that answers that. So essentially it's incumbent upon making sure you disclose who your primary care physician is and that way that documentation of that visit and the disposition of that visit can be provided to your primary care for continuity of care purposes. And do you have any way to measure to what extent the telehealth services actually try to elicit that information and then actually get it through to primary care practitioners? I say this because that's a major stumbling block here if it falls through the crack and the primary care doctor, she doesn't know actually what has happened with her vision. Sure. And as a primary care physician, I completely understand that communication and seamless communication is is always critical. So we do have, we don't know this as a known problem among Vermont members receiving services and full disclosure that the uptake of and utilization of the of the telemedicine service that was available pre COVID for us was quite low. So I wasn't aware of any specific problems. We obviously are watching this very closely as we see a lot of service being shifted to the virtual environment. And so that's an area of critical priority for us in New York state where there have been concerns raised about provider communication. We have used the the Rio's the regional health information exchanges to be able to wrap around that information as well as some internal workarounds that is based on claims to be able to push that information to the primary care physician. Thank you. Thank you more. Are there other members of the public who wish to comment at this time. Hearing none. I wish to thank Dr. Kelby and Mr. Otarizzi for a very informative presentation. Dr. Kelby we wish you had hung around Vermont after graduation from UVM and practiced here but I have many colleagues and friends that I visit when I come up so I feel still very connected to the to the provider community there. So if you're talking to any colleagues and friends that chose the urban areas to practice and this might be a good time for them to reconsider and move to Vermont. I will make sure to remember to mention that. Okay. Thank you very much. At this time we're going to turn it over to sigma. Dr. Pierce Anthony Cali and Christine Cooney. And again do you have a presentation that you're going to share? Do you want Abigail to do it or what? Hi it's Anthony Cali. Good afternoon and thank you for the time. We do not have a prepared presentation. We did provide a link to our website at signa.com backslash coronavirus which can give detailed information on how we're supporting the our customers during this pandemic. So I'd like to walk through what we're what we're doing. If it's okay with you. Certainly. Okay. Again, thank you for the time this afternoon. I appreciate the opportunity to to spend the time and talk with you about what signal is doing. Let me first start by by highlighting that it is and continues to be available 24 seven for our customers and our providers in the community. So if our customers need us and need to reach out to us, someone's available to speak with them. Same with our providers across the country. If they have questions, they can call in and talk with someone at signal. We as well early on during this pandemic, the transition employees who do not need to be in the office to a work at home setup so that they can continue to be available for our customers and our providers. And we've also increased staffing support around claims to ensure we can continue to turn claims around in a timely manner and get those statements out to the providers. We do also or have offered telehealth or virtual services. We've been offering it for quite some time now. It is available either through your the sigma your signal customer. You can get it through your portal or you can also get it through the signal mobile app. We have medical doctors available. We also offer tele behavioral health. And we have recently launched tele dentistry for our customers that need access to an emergency dental consult. They're able to contact a dentist if you have the signal dental program. Let me start here at the top. Let me just walk through some of the things that we've done. As well for our customers. So, sigma was one of the first. Areas to wave cost sharing co-payments for COVID-19. So we wave the cost sharing for office visits related to COVID-19 and testing through May 31. We wave customer cost sharing and co-payments for COVID-19 treatment through May 31. And we wave customer cost sharing for telehealth screenings for COVID-19 through May 31. We've also waived prior authorizations of transfers for non COVID-19 customers that they're transferring from an acute inpatient hospital setting to an in network long term care or other subacute facility setting. We are providing free home delivery for of up to 90 days supplies for maintenance medications that are available through our express scripts pharmacy and 24 seven access to a pharmacist. We've also partnered with buoy health, which is an artificial intelligence power navigation platform to provide free web based interactive triage to assess COVID-19 risk. We also are offering a free on demand webinar for the general public with tools and techniques for stress management and building resiliency. We're also offering resources for all customers, clients and communities to support them during the times of high stress and anxiety with a 24 hour help line to connect people directly with qualified clinicians to help provide support and guidance. We have a, as I mentioned, our tele-dentistry, which is available to to see the customers. We have also a dedicated internal team to answer customer questions related to COVID-19 billing or claims questions. In addition to customer support on the provider side, so we have our national platform for our provider network, and we have collected and we continue to monitor provider questions and concerns nationally, not just in Vermont, but with providers also outside of Vermont. And we've created on our provider portal and easy to use accessible link for the provider community to see what the signal billing requirements are to be paid for the services they are delivering, whether it be a virtual care or COVID related services, testing or treatment. We continue to maintain that site. It's updated on a regular basis, so we continue to take provider questions that have come in nationally, and we add them to our providers frequently asked questions site. And we'll also update our billing guidance and requirements as necessary, whether it be through executive orders that require to be changed or whether it be through feedback that we've collected from providers across the country. To communicate that information with the provider community, we've done social media posts. We've emailed providers hundreds of thousands of emails nationally. We've also made personal outreaches to small, large groups and big delivery systems in our markets and across Vermont. We've hosted phone calls with the providers to walk them through and help answer any questions they have live. We've spent time with the hospital associations and markets across the region, as well as with the medical societies to answer any questions they have, and also participated in government sponsored calls similar to this one to answer questions related to how we're supporting our providers in the community and the services that we're offering to our customers in the community. Also covering the COVID-19 screening testing, whether it be laboratory testing with no cost share for our customers through May 31. We're allowing for accelerated hospital long term acute care transfers in waiving the prior authorization requirements for that. Let me just step through here. So for virtual care, SIGMA is allowing providers to bill for services that would have been delivered in a face-to-face setting and be reimbursed for those as virtual care. We are not putting requirements on face-to-face at this point, so if they deliver the care, whether it be through telephone or through video, whether it be through our MD live partnership or through the local providers offices, they're able to receive that care and the providers can bill for that and get paid for it. We are monitoring claims, and we're looking for all COVID-19 related claims as they come in, and we're looking for scenarios where a provider may have billed it a claim incorrectly, but to avoid payment to a provider rather than denying the claimant claim for incorrect billing, we're actually proactively outreaching to those providers, and we're walking them through how they need to correct the claims to get paid. So we're trying to avoid any time delays in between claim denial and getting paid, so we're trying to be proactive there and walking those providers through that. And we're also looking for scenarios where they may have used all the right diagnosis codes, but maybe they missed a modifier, and we're trying to get those claims processed and paid quickly without having to deny the claim back to the provider. We are also offering virtual care for occupational speech therapy through May 31, and we, again, we're encouraging our providers to visit our provider portal. Many of them across the country, including Vermont, are accessing it today, and we continuously update that with new information around any new billing guidance that we have related to, again, other executive orders or through changes that we make. From feedback from providers to make claims payment easier or billing easier for the local provider. And let me just pause here for a moment. Dr. Pierce, do you have any additional ads before I continue? I think that's a good momentum. If there's other things that you wanted to add, go ahead and then we'll open for questions. Okay, great. So, we have also created in partnership with New York life, the brave of heart fund. Both New York lights and sigma committed $25 million or contributed $25 million to start the fund with a goal of reaching 100 million. And the fund is set up to support or provide funding for the frontline healthcare workers that are impacted by the COVID-19. And if there are healthcare workers impacted by it, they can fill out an application for funding at www.raveofheartfund.com. And that was set up. I believe that website, if it's not available live yet to fill out the application, it will be up there shortly. So providers and communities all across the country can apply for that support. And I think that's it. I walked through that kind of quickly. Any questions? Okay, we're going to open it up to the board. Maureen. I'm fine. I think that was, I think when you go last, presenting up to the other two insurers, we've already covered, you know, a lot of this. And so it's, it's refreshing to see, you know, all three are really going at this very, in very similar manners. But thank you very much for the presentation. Thank you. My only question is how many members do you have in Vermont? I don't have the current numbers in front of me, but about 50,000 if I have the numbers right. Thank you. Okay, Robin. Hi. Thank you for joining us. It's great to get an update from Sigma. I was curious about your self-insured business because I think the vast majority of not almost all of your business in Vermont is self-insured and whether you were seeing adoption by self-insured employers to similar policies to what you outlined today. I want to make sure I understand the question you're asking if our self-insured employers have adopted the policies. Yes. So, yes, largely they have there for the treatment component of it, 95% of our clients have adopted the coverage with no cost share. Great. That's great news. It's helpful for us to get a sense of how it's impacting Vermonters because particularly in your case, a lot of your business is self-insured. So, thank you for that. I was also curious if you have been thinking about either in Vermont or in other states where you do business fixed perspective payments for providers and whether that's a payment policy that you'd be interested in looking at or pursuing. So the question has come up and it's something that we've heard from providers at this time we're not doing it. Okay. It's something that we are certainly looking at as a benefit both for cross containment as well as stability in our all-pair model in our ACO program in Vermont. We would encourage you to think about it in that context because we really are trying to do an all-pair approach here. So just with curious, your take on that. Thank you. I'm good. Thank you. Yes. Oh, thank you. I guess my question revolves around some of the similar questions I've had of the other carriers and it would be helpful for just consistency to understand what's happened to your claims experience in terms of what's happened to hospital medical claims, professional medical claims and drugs. Medical claims and your membership experience over the past five to six weeks. So it's a lot of providers, as was mentioned earlier, have postponed elective procedures. So we're expecting to see a decline related to that. However, I do not have a detailed financial summary that I'm able to share publicly at this point. We continually are monitoring our claims, our experience and our volumes, and we have a report that I'm able to share publicly. I'm happy to come back to the group. Christine or Tiffany, anything to add there? No, that's the stage. It's really monitoring at present. Can you repeat that? I didn't hear the last speaker. We're still monitoring claims at present. Okay, well, we also to the degree that the board has there's opportunities for confidential submissions. It'll be, we can talk further about whether that might be a potential here to share confidentially. Thank you. Those are my questions. Thank you. At this time, we'll open it up to the public for any comment. Does any member of the public wish to make a comment at this time? Hearing none, I'd like to thank the team from SIGNA and, you know, it's been fascinating listening to our three principal insurance carriers in the state of Vermont this afternoon. And certainly a lot has been done to try to help in this unprecedented time. So we thank you. And at this time, is there any old business to come before the board? Hearing none. Is there any new business to come before the board? Hearing none. Is there a motion to adjourn? So moved. Second. Been moved and seconded to adjourn. All those in favor signify by saying aye. Aye. Anyone opposed? Thank you everyone and have a great rest of the day.