 Good morning, everyone, and welcome to the Green Mountain Care Board meeting. My name is Kevin Mullen, Chair of the Board, and I'll call the meeting to order. The first item on the agenda is the Executive Director's Report, Susan Barrett. Thank you, Mr. Chair. Good morning, everyone. The first item I have is that we have some agenda changes for today's meetings, and I want to report those out to start. We'll be adding, actually, switching the timing of the wait times update. It's currently on the afternoon agenda, and we're now moving it to after the insurer's presentation this morning, so it'll probably start around 11. So I wanted to alert folks to that. The next change on the agenda is that we will be... Sorry, my dogs are coming in. We will be taking an item off of the... Well, there will still be an item on the agenda. I was informed late yesterday that the Department of Mental Health will not be attending the meeting today. They have submitted some written comments in lieu of their in-person appearance, so the Board may want to still discuss those comments and have questions for the Department of Mental Health. We have invited them back to present and share their work with the Board, and that hopefully will happen next month. And those are the two agenda items. Are there any questions on that from the Board? So do we have that letter from the Department of Mental Health posted on the website? We do, Mr. Chair. Yes, that is under today's materials, and I believe it's posted under what's new as well, so folks can get that handily. Okay, great. Thank you. The other items I have are two public comments. So there is a public comment that I've been reporting out for almost a year now, actually over a year now, that the Board is accepting public comments on a potential next agreement with our federal partners at CMMI on an all-payer model agreement. Any of our comments we share with our partners at the agency of human services and the governor's office as they are leading the negotiations on the next potential model. I also want to remind folks that the Department of Financial Regulation and the Vermont Health Access have prepared materials and presented those materials on the new EHB benchmark plan. And they have a link to that, those materials on the Department of Financial Regulation website. And so if folks want to comment, please click on our link under public comments and it'll direct you over to the Department of Financial Regulation website. The last thing that I wanted to mention and alert folks to is that on our website we've posted the Department of Human Resources posting for the new Board Chair as well as Board vacancies. And so if you have questions on that, you would want to direct them to the Department of Human Resources as they run the recruitment through the GMCB Nominating Committee. And that is all I have to report, Chair Mullen. I'll turn it back to you. Super. Thank you, Susan. The next item on the agenda are the minutes of Wednesday, April 20th. Is there a motion? So moved. So moved. Seconded. It's been moved and seconded to approve the minutes of Wednesday, April 20th without any additions, deletions, or corrections. Is there any discussion? Hearing none. All those in favor of the motion please signify by saying aye. Aye. Any opposed signified by saying nay. Let the record show that the motion carried unanimously. So now we're going to go right into the main topic of discussion this morning, which is an update from Blue Cross and MVP on payment reform efforts and general updates. So I'll turn it over to the two insurance companies. Sarah, were you going to moderate this? I think Sarah was going first, right? Sarah, and then MVP after you. Oops. Captain Lucille de Vermont. And with me, I have Grace Gilbert Davis and Luma Clarence. And Grace is actually going to kick off the presentation and pull up the slide deck, I believe. I wasn't sure if I was opening and bringing up the slide deck. But these folks, I'm not used to working in on this platform. And there it is. And we can see it. And there it is. Great. Okay. Now let's see if we can't make this a little bigger. Can you all see it? Hey, Grace. Can we put it into presentation mode? Yeah, I'm trying to do that, Lou. Are we good now? Yes. Okay. Great. Well, good morning, Chair Mullen. Member Holmes. Member Pellin. Member Walsh. Green Mountain Care Board staff and community members. My name is Grace Gilbert Davis. And in my role as Corporate Director for Healthcare Reform and Quality, I am responsible for aligning Blue Cross's value-based work with OneCare Vermont, our network providers, and our community partners. And I need to move to my next slide. Today's agenda speaks to the Green Mountain Care Board's questions about Blue Cross and Vermont's efforts to support the all-payer model through our long-standing collaboration with OneCare Vermont, our growing value-based programming developed by Vermonters for Vermonters, our understanding of the impediments we face in our reform work, and our innovative cost-containment achievements past, present, and future. Apologize, I am having some challenges with advancing slides. If someone could provide me with some guidance as to how to advance, okay. Next slide. Thank you. I would like to start by sharing our Healthcare Reform philosophy. We truly believe that we can only achieve reform by partnering with our providers and stakeholders, because only by working with people on the frontlines of healthcare can we truly achieve our goals to improve clinical outcomes reduced to cost of care for our members and employers and maintain exemplary member experience. And we achieve these goals by developing value-based payment models through our partnerships with OneCare, with providers and stakeholders that are straightforward in design and implementation. If it's going to tell you, Mrs. Dara, I think I'm controlling the slide. Don't tell me when you want to advance. I apologize. I said, good to know. Okay. So our collaboration with OneCare began in the beginning. We were the single commercial payer with OneCare until 2020, roughly 70% of Blue Cross providers contract with OneCare. And our contribution to member attribution has grown annually from roughly 30,000 plus in 2018 to more than double that number, or 62,445 in 2022. Next slide, please, Sarah. Not the right one, Grace. I'm having a problem, too. Sorry, one. Thank you, Sarah. Standing shared risk and savings arrangements began in 2014 with shared savings programs through 2017. In 2018, we saw the introduction of shared risk and shared savings. With the advent of COVID, Blue Cross and OneCare pivoted, agreeing to a capped shared risk savings agreement for QHP and primary. However, we did use the COVID years between 2020 through 2022 to develop a fixed prospective payment pilot offered to Vermont hospitals and independent providers. More on that to come. And we also developed an implemented, excuse me, an annual quality work plan in collaboration with OneCare. And as we plan, I'm sorry, Sarah, can you please go back? Again, what remained a constant was our quality work, our commitment to the 11 quality measures, continuing and even evolved. When, again, as I mentioned, we developed an annual quality improvement plan that we hope to expand over time to include measures that support the healthcare needs of the monitors. There are ongoing lessons learned that have helped Blue Cross identify the challenges we face in our work with OneCare. And I will turn it over to Sarah to explain those challenges for the slide flow net. So I'll explain some of these now and then we'll get into more specific with the program. But some of the impediments to success that we have experienced from the player side are the slow growth in attribution. And I think what you've seen and you all know is that many of providers are participating in the Medicaid program, but have been slower to participate in the commercial program. The next, and this is very important for us, is that it excludes retail pharmacy. And as you know, and as we discussed often, pharmacy is a major cost driver of premiums and an area of concern for us. So this is one we'd like to continue exploring. The third, the lack of actionable reporting and analysis for providers of Blue Cross, what we've heard from providers, but also we see when we view the data is that it's hard for us to, the data is sometimes delayed and sometimes not detailed enough for us to really use it in a way to help providers and to work on cost containment initiatives and care coordination. And then that leads into the lack of clarity around the care coordination role. So I think you've all heard some of the discussion here and there's a difference between panel management and care coordination and some other tools that are being used. And so just making sure that we work together to make sure that everyone's on the same page and working on aligning our priorities and our actions, it would be important. Did I miss anything, Grace? No, you did not, Sarah. So the next one we want to talk specifically about is the fixed perspective payment pilot with Southwestern Vermont Medical Center and a few, a handful of, more than a handful, of primary care practices. So in 2019, OneCare Vermont approached us about developing a fixed perspective payment pilot. It's considered a critical step in the development of the all-payer model and a number of hospitals were considering the program as our understanding. This was clearly pre-COVID. Ultimately, only one hospital chose to participate. And the pilot began in April of 2020. So that's definitely unfortunate timing. And the payments are for our qualified health plan lives only, which is a fairly small number in the 15,000 attributed range. And then also in 2021, we added 11 independent primary care practices. So it's been good for us to be able to see how this works with a hospital provider and then also with independent primary care providers. Since there was different approaches with each of those. I should have said right up front that we are the first pair to enter into one of these fixed perspective payment contracts. It's not a true fixed FPP. We do reconcile at the end of the year to claim. But it was important for us to start out as a pilot and see what we needed to do. I think the one other thing I wanted to talk about on this slide and the reason we have the diagram with the triangle in the corner is that it's a three party relationship, but we're not all participating in all three parts of the relationship simultaneously. So we maintain our typical contractual relationships with the provider for the delivery of care, negotiating the rates on fixed perspective payments. And then one care of Vermont is maintaining the provider and grievance with the ACO and the provider. So for the fixed perspective payments. There are some areas in the contract and the relationship that we don't have a clear parent vision into. And then what we do at the end is true up to the claim. And that's the same for both the hospital and the independent practices. So I'm going to move to the next slide. So it's care responsibilities by all three parties. And then this was to give you some information about what we've learned and what we believe we need to do more of going forward. So the pilot really did allow all parties to test the implementation of just the operation. So system development, IT changes, actuarial analysis. There's a lot of work behind the scenes that needs to happen in order to make these line up and work together. So a lot of that was good that we had a pilot so we could work on those things. I think I'll jump to the fourth belay here. So currently, we do see some problems in the way that it's operating. And I think with some time and investment, we could get over those hurdles that are operational and we believe that we could fix those. It does at this time, however, seem like a significant commitment for such a small membership. We're only doing it with one hospital and a few primary care practices. It's outside of the goal of how we operate. And then let's see. I don't think I need to say it, but having this pilot begin during COVID also, I think everyone was distracted at least for the first year with numerous other things. And this wasn't the highest priority project at least for the first year. So that's been, I think, one of the difficulties with this as well. Another thing is that we really need to see, and Grace talked a little bit about our healthcare reform philosophy. She'll talk about that 10 minutes later. We need to see benefits from these programs for our members when we commit the time and resources into them. And there's no clear distinction between the fixed perspective payment program and other programs through OneCare Vermont, say, and the quality and the financial benefits. So that's one thing that we would like to see more of going forward. And the last piece, and I think you all know this, but fixed perspective payment and isolation, we don't really believe can drive system reform. It really needs to be paired with other efforts in order to see success. And things like that are the internal financial incentives at the provider practices. We feel that those need to also align with the fixed perspective payments. And there's still a lot in our system that's geared towards fee-for-service. And the last, I had one last thought. The last thought we had on this is we really do see this as a way to move forward. And the risk is another big part of this. We believe that the providers are still hesitant, partly because of what's just happened over the last two years. And we really haven't returned to a stable system, as you've seen. And so that is another thing that really is holding us back. And I know that we want to be set up to move forward as soon as we feel that it's the right time. But OneCare Vermont really needs to work with the providers and let us know when it is the right time to take on more of these projects and move away from the reconciliation piece. So I believe Lou is starting on this one. I am. Thank you. I'm Lou McLaren and I'm the Director of Provider Services at Blue Cross and Blue Shield of Vermont. Grace started off our presentation talking about our healthcare reform philosophy. It's really setting up the overarching approach that we want to take in our healthcare reform efforts. These three tenants really, there are beliefs on how our reform efforts need to move forward and how they're actually operationalized. And I think it's probably important to let you know that healthcare reform activities don't just sort of come out of the provider contracting arena. We get ideas and think about opportunities and discuss and share them. Providers come to us with ideas. There may be some activities or ideas for programs that arise through our utilization management teams or our integrated health teams care coordination. But no matter where the source of the idea or the program comes, we have to focus on these three tenants. We need to be able to feel with a high degree of confidence that a pilot that we develop or a program that we're planning to implement can deliver on benefits to the members and the employers. And really, that's measured through cost savings, premium reductions or the quality, the focus on quality, which is the second tenant. Quality can be super big to wrap your arms around and we need to be able to drill down to quality measures and activities that have meaning that you can actually show, deliver. You can touch it, you can feel it, you can see it, you can measure it and you can take action on it. Historically, I don't know that we've collectively as a healthcare system been able to accomplish that successfully, but we've really come to believe very strongly at Blue Cross that it has to be a lot easier than maybe we've made it in the past. And the final thing is really the data integrity. It may be something that's not particularly discussed with great regularity, but moving to any sort of a global budget or fixed perspective payment, it doesn't mean that you leave the world of submitting claims or capturing the data around the care that's delivered because you need those data and you need all of those data points in order to do the measurements that we're talking about in number two as our second tenant. So we can't lose sight of the data collection and how important it is to be able to demonstrate the success of our programs. Can you go to the next slide, please, Sarah? Oops, back one. This is a very sensitive program it looks like. I'd like to talk to you and really to share and to boast about some of the current programs that we have in place here with Blue Cross. And I think what's important to recognize is that the programs I'm going to share with you, they really span the spectrum of providers. So we have programs that are with a hospital, we have programs with designated agencies, we have programs with the home health agencies, mental health and substance use disorder providers, and sort of the last bullet is really a compilation of provider types that I'll talk about. But the first, the in-home program for mental health services, this is a new and really innovative pilot that we have. It started with Howard Center. It now includes HCRS and we're looking to expand it to additional designated agencies. This is a program that's targeting children and youth who are at a crossroads in their care. We're either trying to keep them out of a higher level of care, like being down at the brad of our retreat, or maybe they're coming down from a higher level of care and they can't quite transition fully to outpatient therapy that they need something that's got a little more scaffolding around it. And so this is a program where it's a bundled monthly rate and it provides assessments, enhanced care coordination, and supportive counseling for these children. It's been an exciting program for us to enter into with these two designated agencies. It's really filling a niche that we are recognizing and I think that all of the conversations that have taken place over the past few years around the need for better access to mental health and substance use disorder, particularly for the child and adolescent population, we're trying to find a way to provide the care that's needed, recognizing the limitations that we have in access in the system in general. During COVID, obviously some of this was not in home, but it was done remotely, so it has that adaptability and can certainly flex with the patient's needs. The second program we have in place, this is a hospital program. It's a shared savings program where we have two bundled rates for your the two levels of colonoscopy. We've entered into the agreement. It's been in place for probably about three or four years now, and it has produced shared savings that we do share with the facility. It's something that we want to expand across the state, and it really lends itself to being a bundled service. This is a high volume service that in many ways could almost be considered a commodity. If any of you've had colonoscopy, your experience may be that you and your primary care provider have identified that it's time for you to have one, and you really just make the appointment. You don't necessarily meet with the surgeon beforehand, so it is something that as far as surgery is concerned. It is a relatively simple low-risk surgery that we think is a really good way to demonstrate opportunities to work with our hospital partners to develop a shared savings program. The third program we have in place, this is pretty unusual. This is a quality-based performance program that we have with the home health agencies, and this designs with them. It was around two tiers of reimbursement, and it was what we call a gate and ladder approach. There were some baseline quality measures that the agencies needed to meet or exceed, and that got them through the gate. Then once they sort of qualified, there were then some additional quality metrics that were important both to the home health agencies and relevant to Blue Cross. Then they had performance targets in those measures as well. We did find that there were a number of the agencies did qualify for the higher-level reimbursement. It's a program that's tough. It's tough for us because as a commercial payer, we are not the lion's share of the patient population that is being served by the VNAs, but we still continue to work with them. How can we make it more meaningful and more robust for both parties recognizing that probably the biggest limiting factor is the low volumes? The fourth program we have in place is called the Feedback-Informed Treatment or FIT, and that is not to be confused with the FIT test that is used for colorectal cancer screening. It's unfortunate they have the same acronym, but I'm talking about something that's for mental health and substance use disorder care. This is working specifically with the outpatient therapist provider category. It's a program where the providers are trained. It takes a level of engagement on their part, and really what it is is it's a program design that offers a continuous feedback mechanism between the client and the provider. Really what it's measuring is, does the client perceive that there's advancement in their care or not? That's an opportunity to do a mid-course adjustment to the treatment approach if the client's impression is it's not working. It also measures and takes a look at the client's perception of his or her relationship with the provider. It's a highly engaged program for the providers that do participate in it. We provide the training, we provide the resources, and they are on enhanced fee schedule. Now the success of patients who are treated by a FIT provider or by providers who adopt the FIT approach, you see a lower dropout rate in care, you see a lower rate of hospitalization, lower length of stay if you are hospitalized, a lower rate of deterioration in the disease state, and a lower total cost of care when compared to control groups. It has been wildly successful nationally in the body of literature, but we've also been able to determine that we've seen those successes with our Vermont population. And the final program I'd like to talk about, this is really exciting. This is a collaboration with the University of Vermont Medical Center. It's a non-invasive integrative pain clinic. It's a pain program that lasts 16 weeks, and it encompasses a variety of services. It is not just physical medicine, it incorporates the mental health component of medicine. They're looking at, physical medicine visits, group and individual therapy treatments, but then you move on to the services that aren't standard benefits. There's the whole food and eating for health, and the nutritional counseling is a covered benefit, but learning how to cook in a way that's appropriate to help you treat your pain. Massage therapy, yoga, acupuncture, mindfulness, all of these services are available to the Blue Cross participants, and I don't mean to dismiss or make light of this. It's almost like it's a buffet, and each patient's care is tailored so that I may be needing physical therapy twice a week for the full 16 weeks where someone else may be able to do it once a week for half the program, and then they're done. They may be succeeding more under massage and acupuncture, whereas that hasn't worked for me at all. So it's a very customized program within the program design. We have a bundled rate with the University of Vermont Medical Center. The success that they have seen thus far is very promising, and it's just something we're so excited to have up and running right now. We are looking to expand it. Northeast in Vermont Regional Hospital has expressed interest in it, as has Springfield, and so we're in conversations right now with both of those facilities. And I think, Sarah, that's it for me. Gracie, are you tackling this one or am I? You can go for it if you're ready for it. I am. Okay. Moving through what we currently have in place for value-based programs, but we are also looking at new and innovative program expansion. I'm going to start with, we're very excited about our advanced primary care model that we're in the process of launching this year. Developed in partnership with providers and using the Institute for Healthcare Improvement's quadruple aim as our guide. The model is a very simplified, very integrated approach to healthcare that improves value and outcomes while maintaining, and this is really important, maintaining the exemplary experience, not just for patients, but for providers as well. That is part of the quadruple aim, is that the providers are part of the entire vision for improved healthcare and work satisfaction, workplace satisfaction. There are three sort of components to this advanced primary care model, disease management, transformation of care, which is tools to help providers transition from the fee-for-service model of providing care to a model where they can work in a capitated environment. Then the third component, so important in primary care is to reduce, if not eliminate, gaps in care. That would mean a high panel management, identifying patients who have not had annual physicals over an active amount of time, getting those people in, making sure that we're managing diabetics, patients with hypertension and asthma, all of the chronic diseases that we see here in Vermont. We look forward to providing you with more information. The launch will take place this year. We will take 12 months working with the participating providers, and at the end of that 12-month period, we will audit the program, looking at the metrics that are in place, both for quality and cost of care, and surveying the providers to understand what worked for them during this pilot period within this model and where their opportunities for improvement. The second one is, again, something that is near and dear to my heart. I like to say that we're the proud sponsors and active participants in the Trauma Informed Care Initiative that is being led by the Health Center in Plainfield and Dr. John Matthews. Under Dr. Matthews' leadership, the Health Center is actively working to become the first trauma-informed, trauma-trained, federally qualified health center and primary care practice in Vermont. This is going to be accomplished by training all of the staff to understand adverse child events and to understand the link between the trauma that's placed in childhood and health issues that arise later, whether it's in late childhood, adolescence, young adults, or even frankly in adults of any age, and to be able to work in advance of those health issues becoming apparent. Again, it's pretty exciting. We believe that, again, with Dr. John Matthews and with the help of other individuals in the state, including Tom Reese, that once this program has been tested with the Health Center, that the goal is to then move it to all of the federally qualified health centers in Vermont. And then a pilot that is still in the research and development phase is our Centers of Excellence work through the Blue Cross Association's Blue Distinction and Blue Distinction Plus program for hospitals. I really can't say much more other than to say that we're looking at orthopedics and perhaps imaging down the line, and we are definitely looking forward to providing the Green Mountain Care Board with further information as the pilot evolves. So just with our work with OneCare, we have learned valuable lessons as we develop and implement value-based pilots and programs. And Lou, I think you thought you were done, but I believe that you're going to walk us through the lessons learned if I'm not mistaken. Okay, lucky me. So I'm going to check in. Sarah, was that you or was that me? I'm sorry, it sounds like we don't know the left hand on the right. Okay, I will take it. So we definitely have over the course of the past five or six years that I've been with Blue Cross, we have dipped our toe into value-based pilots and we've started some, we've ended some, and we've continued some, and we do feel like we've established a body of work around what worked and what hasn't. One of the first things that's critical, no matter what program you want to join in with partnership with a provider, there have to be champions, both in the provider community and within Blue Cross to basically be the ones that are going to help move the respective institutions forward to make sure that this program can get implemented and stood up and working. You can't jump into any sort of value-based programming half. You've got to jump in with both feet to be fully engaged and committed. And that includes being able to rally the support within your respective organizations. Flexibility and adaptability is something that we've learned recently. We're in a current pilot program with Evergreen Family Practice and we started it a year ago and it was very heavily informed by their experiences that we were having to sort of pivot and redesign and simplify our pilot sort of mid-course. But that actually engaged all of us much more strongly because we realized what their, what their perception of the program was and where they thought it could go really was valuable feedback and it didn't make sense to wait to make those changes. So mid-course corrections sometimes may throw a monkey wrench in some of your evaluations, but the flexibility to be able to adapt should remain. Whether it's utilized or not, that's going to be determined on a pilot-by-pilot basis. From a measurement and evaluation standpoint, you really, there are some conflicting end points here. On the one hand, you want to have this really robust set of measures and you want to drill down and you want to be able to just get measured to the nth degree or success or failure, but that can become overly complex and unwieldy. So we're really trying to find where that sweet spot for the measure that makes sense, the measures that have value to the provider, to the member and to Blue Cross, and are they simple enough to implement, measure, track, trend, you know, and take action on? And that's really sort of the second bullet. You can't measure for measure's sake and you can't just do it because it sounds good or it's nationally done, but if it's a measure that sort of has a hollow resonance that there's no real underpinning, you got to, you got to think twice about whether that makes sense to adopt. And then the payment structure, the payment structure is really where the rub comes in, sometimes with the providers, because we're asking them to do more things or new things and you need to make sure that you're compensating them fairly for what you're asking them to do and what they're agreeing to do. You know, whether it's a fee for service plus a cap component, whether you're trying to do a bundled rate or where you're trying to do fixed perspective payment, the priorities of the providers and Blue Cross has to be met. It cannot be a one-sided conversation and I think the collaboration really lends to that conversation. I would say that in past years, all payers could acknowledge that a lot of our payment reform efforts were sort of a top-down conversation and a lesson learned is that that doesn't work. And then the incentive payments are really critical to any successful value-based program, but they have to be meaningful. And I don't mean they just have to be big enough to catch the attention of a provider and incentivize them to change, although I won't minimize that enough money makes sense and helps to engage the provider community, but it has to be the right sort of incentive. It has to be linked to an action or a service that everyone agrees. The money makes sense to link it to this thing and that those two together will make your program successful. What we have to avoid is a reimbursement stream that just sort of loses its power and its linkage to your activities. It can't just sort of become part of an expected revenue stream without like a call to action tied to it. So this is what we've gained over our years of experience and I think that that's done for the lessons learned and I think we're going back to Grace or Sarah. And I just need to advance the slide one more time. There we go. So you did ask the Green Mountain Care Board asked us to speak about cost containment and I will tell you that I cannot do each of these programs justice. I think each of them could be an entire presentation unto itself. So I'm just going to give you the high level and we can certainly follow up with additional information later and also when Dr. Flavin is able to participate. He can certainly provide a lot more information on these. So the first is our Vermont Blue Rx Pharmacy Program and because pharmacy as I mentioned before is one of the largest cost drivers in healthcare, this is certainly an area that we focus on for cost containment. Then we do a number of things and have a variety of programs that all fall under this umbrella of the Vermont Blue Rx program. So I'll just list a few of them and then talk a little more detail about one of our programs. So we obviously negotiate lower prices through our PBM and rebate. We also have step therapy programs and also program that we only pay for specialty drugs that actually help the patients. So if the member has to abandon the course of therapy in the middle, we are not required to pay for those drugs. So it's a way to make sure that that we're doing the right thing for our members and not charging them for things that aren't working. But the one part of the program that I wanted to speak to the most is we now have two additional pharmacists who work directly with members and providers or patients with complex and chronic conditions who are taking a number of different drugs that could conflict or may have side effects. So usually the pharmacist will do a full medical review with the patient, all of their records from all of their providers and look through each drug one by one. They try and understand how the patient is tolerating the medication, how long they've been taking it, if they have side effects that may be making it difficult to take a particular drug or if it's interacting with other drugs in a way that harms the patient or even just doesn't make them feel very good. And then they're also of course looking at cost. So if there are lower cost alternatives, they work with the member to see if that would be helpful for them and also were to obtain them at the lowest price and then they will also work with the patient and the provider to get the restrictions changed if that's necessary so they can take advantage of the drug. So that, I believe, is a really interesting program. I think our pharmacist came and spoke to one of the Green Mount Care Board committee for primary care and it's an interesting and innovative one and it really reaches out to the member and the provider together to collaborate to make the drug regimen work. So there is more informancy but I will switch now to the lab benefit manager. I believe it was a year and a half ago that we began an agreement with Avalon and we before that didn't have a network for laboratory and we were seeing, it wasn't in Vermont so much, but out of state labs where often people's work is sent that the prices were not, they were very high and so working with Avalon we were able to create a lab network and pull down costs and also create better relationships, I believe, between the provider and the laboratory that they're using. The next one, I know we've spoken a little bit to the Green Mount Care Board about CIVICA Rx. We really believe that this is a completely innovative way to approach drug prices by manufacturing and distributing them in the lowest cost method. We believe that this could help pick up the distribution of drugs and the pricing of drugs. So this started out just to give you a teeny bit of background if you don't remember. It began with a coalition of hospital systems to manufacture generic drugs that they were having a difficult time obtaining and so those are on the medical side. Then they created a new subsidiary with partnership from Healthland and so the blue system is a big part of this, but there are a lot of other partners, other insurers as well as the state of California and what we're looking at on this side is to manufacture generic at retail. They are just beginning to be introduced in the market. I think some of the first ones will hopefully be this summer. We have to make the investment upfront and take some time to see the results and then the second piece on this that we announced this winter was the investment in a facility that's going to manufacture insulin and the really interesting part about the insulin piece is that this will have a MSRP, essentially a sticker with the price on the drugs. I think for some of the insulin the average price is about $180 and this is expected to be $35 so we really want to pass the savings on directly to consumers and insulin is a state that everyone is worried about. So again we could speak a lot more in detail about that about any of these but that's just the high level of what some of these programs are. This is the value-based fit testing program so the one that's not to be confused when we spoke about earlier this is fit testing for colorectal screening. This really got off the ground during COVID. This was one of the I guess positive benefits of COVID when people couldn't go in for their colonoscopy. Providers were looking at ways to help ensure the you know that patients still were coming in for testing and so this was a program we worked on. It's still just getting going but we believe that it really has benefits and it did get a kick start during COVID which was nice. And the last one the provider password program you may be thinking is odd that I stuck it here under cost containment but traditionally PA programs are among the other things cost containment efforts. There's certainly efforts to ensure that the appropriate care is getting the patient at the right time and avoids duplication but the unique thing about our provider password program is now we're trying to achieve efficiencies on the provider side as well by identifying and this is you know what's known nationally as a gold carding program but identifying providers that have very high levels of approval and simplifying the process for them and then reviewing the results to make sure that we're still seeing the same level of outcomes that we've always wanted to look for. So we've got it here it's still moving along it certainly didn't have the volume of information that we need for a federal process because of the you know the slowdown during COVID but we believe at the end of this year we'll have more data to provide real information about the success of this particular program. So that was quick I realized a very high level. Can I just add a little on around Avalon? Yes. So Blue Cross was Avalon's fourth client. We've been under contract with them since 2019 and while we did have our own lab network one of the things that's hard for us as a pair to do is to really scrutinize the value of each lab that approaches us to participate and to to determine the clinical validity of their actual tests because there are a lot of labs that provide tests that aren't you know that they haven't met the rigor of being a meaningful and valid test and so one of the big values that Avalon brings to the table is that because they create the lab network and that's their area of expertise they're able to filter out sort of the fly-by-night labs and the ones that aren't FDA approved and present a fully robust lab network that can meet all of the provider's clinical needs but it's a much narrower network so it offers competitive pricing and we have seen substantial savings through our relationship with Avalon. So I just wanted to expand a little bit about that to say that we do have two years of experience under our belt with them and it's proven to be a really beneficial relationship for us and for our members. So thanks. Thank you Lou. And so I think I wanted to sum this slide up by saying that savings we achieve through any of our cost containment efforts are always passed through to our members in place so that's why we do these in addition to a number of other reasons but we really do want our members to see the benefit. So our that is the end and I'm going to pull this slide deck down so we can see you and hopefully answer questions if you have them. Sure I'm sure that we have lots of them. I'll start off with one Sarah. Where is the manufacturing occurring for the Civica RX generics? There's one facility I believe in North Carolina. They're both in the United States if that's what you're asking and there's another that might be in Jersey but let me verify that one. The insulin is being manufactured in a different facility than the other drugs because there's different requirements for that. Just curious because I've been following the beginning stages of a project in Virginia where the federal government has pumped in a lot of money along with private money working with Virginia Commonwealth University to create a manufacturing facility to make generics to try to apparently there is a supply shortage and I'm not too familiar with that but so I thought that was an interesting concept and I was just curious where the manufacturing facilities were going to be for Civica. So I look forward to that later. I think the other benefit is we having the manufacturing facilities in the United States will help with the supply chain issues that we've been seeing for other drugs during the COVID shutdown. The other thing I'm curious if anyone at Blue Cross took a look at the proposal to try to create a Vermont wholesaler for prescription drugs and if there's any merit to that whatsoever if it just doesn't make any sense. You know so I'm not the expert it would be our pharmacy benefit team and I think our only concern there are scale and volume as a state even if we get every one of our you know members involved across all three payers major payers I mean commercial Medicaid and Medicare that's still not that much volume in the big picture so that's our big concern with that but we're not saying it couldn't work we're just not sure if there's enough volume in our state we're still kind of small. Okay so board members I'll open it up to questions or comments on the presentation that you heard we'll go in alphabetical order starting with Dr. Holmes Jessica. Hi well thank you thank you all of you for lots of updates on interesting initiatives I appreciate it maybe can we actually can you pull the slide up eight just quickly might be the easiest I have a couple questions about that I think we lost Sarah's audio though somehow if it's not possible that's fine I will ask based on my quick notes down here my first all right maybe you aren't be able to pull it out must be Sarah's using Rebecca's computer I think it's number eight it was about impediments to success or obstacles to success or something like that there we go impediments to success so I actually wanted to ask you about a couple of these bullet points a little bit further the one about lack of actionable reporting and analysis for providers and Blue Cross and this is related to the data that I assume that you're getting from one care Vermont right that was what this was in reference to so I wanted to and you said you made reference to the data not being detailed enough and I wanted to ask you if you could provide a little bit more elaboration on that one of the things that I have heard from hospital leaders is that the data that they get is a lot it's very detailed and often it's not actionable in some sense because it's so overwhelming and there's so much detail in there so I'm curious as to your perspective on on the level of detail and what data you would rather see will be helpful and actionable right great so I understand and I know that the discussion of data has been going can you hear me yes yes okay that's what I wanted to make sure and I'll have a great jump into but you know there's been a long discussion about data and as a payer we provide a lot of plain data so that's what I believe we have in probably excessive detail that needs simplifying in order to be useful but what we get back and what we hear that the that the providers get it on some level is too old sometimes you know you need to you need to be pretty quick with the data in order to actually help a member or or you know get in in time and then sometimes it's not detailed enough for the data and there's like panel data provided on on the entire practice and not individual data so so that's some of the I think the issues that we're talking about great do you want to jump in on this one or so put my provider hat on for a moment having worked in the F2HC world for 10 years when when blueprint was actively reporting to practices we received essentially practice specific reports that benchmarked providers within our practice so that they were able to understand their success against their peers and we were also benchmarked against other practices what happened and I don't I don't understand fully where the breakdown took place but the practice specific reports that did have actionable information in them and I know at at Baton Gale Valley Hill Center we used those reports as part of our quality improvement program somewhere along the way something broke and instead of the reports being practice specific they became HSA specific which was just not helpful at all I understand anecdotally because again I no longer on the provider side of the healthcare system I understand that that is still the case in terms of the data we receive from OneCare I think that the report was carefully designed we we don't we don't find a lot of value in it and our goal for 2023 is to work with OneCare to redesign the report in a way where we actually we actually get something meaningful out of the report right well one of the I mean I don't know if there's if there's time and and ability but if anybody somebody could follow up and give us a little bit more detail about what you're missing and what you would like to see in those reports I think it would be helpful so as we do have conversations with OneCare as well and around the effectiveness of the data I think that would be helpful so I would appreciate that if there is a follow-up that could happen that that is not a condemnation of OneCare you know this is reform is just evolving and along with it is how we manage and look at data and so we just see it as essentially a quality improvement project yeah no I appreciate that obviously everything is evolving and learning and we're pivoting and so be helpful to see how it's iterating and what would be most helpful the second one then was I know you pulled down the slide but lack of clarity around care coordination so I would love to hear the solution if any solutions around there about what you would like to see to avoid costly duplication of care coordination or you know to improve effectiveness for patients who need you know high-risk patients who do need that care coordination what is a solution that you see to gain that clarity and or to optimize the use of those care coordination resources I'm going to speak to this one so there seems to be some confusion at OneCare as to whether or not care coordination services are provided I know because I work with the folks that are sort of at the front lines at OneCare that they provide a decentralized care coordination program they have a very extensive and well designed policy and procedure around this program but they don't provide those services directly whereas we do and the blueprint care teams do as well so in our agreement we actually spell out that we will work together to avoid duplication of services that we meet regularly with OneCare but I think I think it'd be very helpful because blueprint is providing these services OneCare is providing albeit to centralize we're providing it as our other payers and providers are also providing care coordination services and it would make sense to bring these four groups to the table and to begin to coordinate these service care coordinate care coordination to avoid duplication of effort and to take advantage of our resources in a more effective and efficient way. Has there been any attempt to put that working group together make a working group? Not to date but we're happy to work with the blueprint and with OneCare and provide a representative to do so. Great. Another question that I have was about the fixed perspective payment pilot that you all have initiated with CVMC and some practices and it strikes me I just as I think about it it's still reconciled to fee for service right so at the end of the day it's really built on a fee for service chassis it's not really fixed perspective payment in some sense it's a bit of a misnomer in the sense that fixed perspective came at the intent of it was to shift more risk to the providers but if it's at the end of the year reconciled to fee for service it's really just a cash flow mechanism but it's still fee for service underlying that so part of what I was thinking as you were describing you know that you're not seeing or it's not clear to you what the benefits to members are of it not surprising if it's really just cloaked fee for service so I'm wondering if you have a plan to move that program towards unreconciled fixed perspective payment like you know true fixed perspective payment and what obstacles you would see from from providers or operational obstacles on your front from doing that making it truly unreconciled or and I think I was trying to show that that's actually one pair is the one that negotiates the contract for the fixed perspective payment and makes the monthly payments so so we're willing to work with them and we want to work with them to move on we recognize everything that you said that that once you're reconciling to fee for service it's not really SPP and to be honest the reconciliation process is pretty cumbersome and so now it's you know more work than it would be if we just paid based on claims or did SPP alone I think I mentioned it and and we should involve the the providers in the discussion of how much risk they're willing to take on and that again is something that is negotiated through one care they're the entity that is taking on the risk I believe for some of the providers especially the primary care providers that are participating now so there's probably different obstacles for the hospitals versus the PCPs and we need to look at them differently and address them that way that's not a full answer but kind of a partial answer okay maybe we should just stop calling that fixed perspective payment and maybe we need another term for it to be honest with you because if it's reconciled it's fee for service with an asterisk that's maybe what I would call it and I guess my last question is I know that Blue Cross Blue Shield has a lot of data that you do have on quality and on prices of services the price variation across facilities and I guess I'm wondering how might Blue Cross Blue Shield share that data directly with providers primarily primary care providers that are actually directing services managing care and making referrals across the state how might Blue Cross Blue Shield share some share some of that quality and price differential data directly with the providers Grace you want to answer the doubter question yes um but let me just go back one minute to your question and we're homes about FFP if I may because we didn't just get this question and we talked with our actuarial department and they asked us to share with you that in order to to move fee for fixed perspective payments forward any capitation models forward first we have to achieve post pandemic stability for providers I mean that's just a given right um we have to work to resume risk in our agreements because as I mentioned earlier you know we right now we have a a tapped risk arrangement with one care because of the of COVID and then we do have to work together to develop a methodology for unreconciled fixed perspective payments and that's something that one care and and Blue Cross are have actively started that conversation um and you know our hope is to continue it 22 and 23 um and arrive at a model that that we can all um we can pilot and understand if it works um and then back to the the reporting provider reporting so through our advanced primary care model pilot we have developed we're developing two reports for providers one will be on the agreed upon metrics so for example um we're going to be focusing on type two diabetics and um patients with uncontrolled hypertension during the first 12 months so we will be reporting back to them and actually meeting with them Dr. Plavin will be meeting with the providers on a quarterly basis but then we have this much larger list of metrics that include patient satisfaction as well as financial outcomes and that's something that we're going to be tracking internally and also sharing with providers so um we'll be back to you with more information and um you know once these reports have been templated and and tested you know in meetings with with the participating providers in the pilot great actually and I think that's very helpful I guess let me just clarify my question um I'm also thinking about when providers make referrals and maybe this is is still in as part of your answers one of when primary care providers make referrals you know for surgeries for colonoscopies for MRIs for for things that are outside of their practice there is information that that blue cross with shield has for example on price variation of some of those services and maybe even quality outcomes of some of the surgical procedures and things like that if primary care providers were armed with more of that information about price and quality variation you know it might help inform be a data informed decision about where their referrals might go so I'm wondering more about that so this is Lou it's great can I take a first stab I just want to remind everyone that we do have our cost tool on our website that we and off all the payers are required to have so that tool is out there and available for both the members and the providers to use now let's be honest the uptake on using those is not super high um but that is an existing tool that provides some really good information um I actually um this has been ironic I'm an FEP member so I don't have access to the blue cross and blue shield of Vermont website I have the FEP website I have a demo of the cost tool that's available and I was so surprised at how much information you can glean as an end user and we do we are looking pretty closely at developing some documentation and some programming around exactly what you're discussing Dr. Holmes is you know are there are there certain high volume services that might be considered more a commodity service where a personal relationship with the provider is is you know I I don't have a personal relationship with whoever x-rays my ankle for example um can we make some information available so that if they have patients who need MRIs or cascans or colonoscopy that they are there they have the tools to present this information to their patients but also it's information that we want to have internally so that we can offer that information to our members as well so that there would be two avenues of distribution um and it's it sounds super easy and in some instances it is but then it's how do you how do you how do you package it how do you get it in front of them because the clinicians are so busy in their offices to give them a tool that they can readily have ready access to that doesn't sort of disrupt their flow and that oh this is the tool for blue cross and blue shield of Vermont members I might have a different tool for a different payer that tells me where they might want their patients going that's that's where we bumped into the potential for provider abrasion and administrative burden all right well thank you I appreciate the answer and all my all your answers I'm done chair mullen thank you thank you Jessica next we move to board member launch Robin thank you um I wanted to follow up on some of Jess's questions around the actionable data um particularly with the aco relationship so the one of the legislature's consultants Donna Kinzer when she was working with hrock had talked about some ways that other states handle uh the data kind of relationship with acos where the payers provide more instead of providing raw data package the data themselves which then goes through the aco so I was just curious what you thought about that idea or any other kind of ideas about how to make that work better on sort of a statewide basis to the point that Lou just made of course um if the provider is getting one thing from blue cross something else from MVP something else from Medicaid and something else for Medicare the light in all likelihood they're you know their heads are going to explode and they're not going to use any of them so how do we try to figure out how to move forward with something that's more actionable from a provider perspective and multi payer willing to take um a stab at that um I I think we we have the mechanism in place through the through the blueprint and if we can um reinvigorate the blueprint program I I think and get back to the reporting that providers received in the past um and and with our help with with the payers help as well because let's face it the best data is is combined claims and and right and and EHR data um but I feel like you know one of the things we do in healthcare is we are constantly recreating in the wheel instead of looking to see what's been done what's been tried and tested and in in my opinion again provider had on I think the blueprint program has been one of the most successful reform initiatives that our state has embraced and and I look forward to its future thank you um related to that I was curious how um and if you've been working with the blueprint on your medical home or your advanced practice primary care program that doesn't mean that we will not in the future okay because to your point I think trying to figure out again how to utilize a statewide approach would be great thank you hold on just a second I'm checking my notes here for some of my other questions so I was very interested to hear about some of the value-based programs that you have been working on and I was wondering if you could just speak a little more generally about how you approach expanding those programs when you have determined that they are successful and um whether you've thought about how to share your successes with um diva or other payers in order to again move forward on more of a multi-payer approach if you had ideas there yeah so um around something like the pain program that is with the university of vermont medical center so we definitely I've talked a little bit about how we've got two other hospitals that are very interested in in creating a similar program you know not adopting a whole plot but designing it in a way that meets their care team and their community needs um and we've also been talking to diva about seeing if medicaid would be interested it you know it has a pretty large population of patients that would be eligible for the the chronic pain program so those conversations have definitely been taking place um I certainly can't I can't speak to the other commercial payers because really this was something that we developed in conjunction with uvm I think they approached us around it so probably some of the expansion to the other pairs would be at the provider side and not on our angle um for something like the in-home program through hcrs and Howard center we absolutely are looking to expand those programs and I don't mean to sound dismissive but you know we we value our innovation and believe that it gives us a competitive edge so it's probably less likely that you would see my contracted team or me reaching out to the other parents to say hey do you want to join in with us um I don't mean to come across inappropriately but you know what we do we think is ours and it's great I would encourage the providers who have these programs with us to then approach their other payers to say hey we have this with this program and then with this payer would you be interested in doing something similar and and that does happen it definitely happens um certainly in conversations that I have with hospitals in the state where they will identify a reimbursement stream or a program that they have in place with some of their other payers and could we model something similar thank you that that you know we recognize that we our our trailers our value-based pilots and programs have have grown now to to the side that we need to formalize how we not only identify new ideas and and implement but how to evaluate whether or not a pilot is successful and should be moved to program status or whether the pilot should be sunsetted because we did not find any value in it and so one of the things that we're working on right now is a essentially an innovation lab and as part of that we will be as I mentioned earlier annually we will be auditing all of our programs all of our pilots all of our programs um internally to understand if if they are meeting the goals that we set out for them both for quality and for total cost of care and in addition we'll be surveying our participating providers um and their staff to understand again where can we improve if we if we've deemed that a pilot is worth continuing to um to work with um so I give you more information but the idea has just just begun to change shape um and we're just at the moment referring to it as our reform innovation lab great um I think that's all of my questions thank you very much thank you rob and next we'll move to board member pelham tom good morning um yes it's still morning and thank you for your presentation um I just have a couple of questions my first is that um a question about where we've been where we are and where we're going um the all pair model has been uh in play for almost five years now we're in our last year a bit and maybe you know it looks like we're going to get an extension of some sort um and there are a lot of moving parts you know as we can see from your presentation uh that are related to value-based uh payments and in health care reform but I think you know I I think that one that is foundational and critical um is fixed prospective payments I mean from from through fixed prospective payments you get the incentive for people to innovate and be creative and to use the resources available to them as wisely as possible and so I'm just kind of looking in the rear-view mirror a little bit here and looking at last year's hospital budget process and the hospitals told us uh in their responses to our guidelines that um overall uh the level of fixed prospective payments was 15.7 percent of all payments now that's not true fixed prospective payments that's a loosely defined fixed prospective payment uh and that Medicare where there is reconciliation was at 33.8 percent of their payments Medicaid uh was closer to true fixed prospective payment and that 43 percent of payments and hospitals I mean commercial was the three tenths of one percent so the hospitals are telling us that um they expected for fiscal year 22 only uh less less than a percent of fixed prospective payments and that amount is 4.7 million out of 1.6 billion in commercial payments and I think the 4.7 million is tied to the project at the southern Vermont hospital if if I'm not mistaken so um and this was kind of confirmed in the rate review process where the index rate was developed and and capitation the amount of capitation in the index rate for both MVP and for Blue Cross Blue Shield was less than 2 percent so I think that's the arena of where we are right now um and so I'm kind of wondering and the ACO also developed kind of targets for different payers and for commercial they were looking for their target in in their budget approval was for 2022 2.9 percent from for 2023 23.9 percent and for 20 fiscal year 2024 44.9 percent now I'm not taking those to the bank but I'm just wondering what do you folks think um I mean we're a long way down the road in terms of reform I think to the general public you know they would say that you know five years seven years you know you know when are we when is this gonna gonna be in place so my question is what do you think the proper target is uh in Blue Cross Blue Shield payments that comprise true fixed perspective payments so we have the the ACO they're saying for 2023 let's let's and set a target for 23.9 percent we're not gonna hit that it's just not gonna happen but so in year six and seven and eight where is the end game in terms of fixed perspective payments where it's a at enough of a critical mass that it's making a difference in the system which we all anticipate that is a good question so you're asking what portion of our total payments should be FPP in order to actually start to drive some change and I don't think I know the answer to that certainly more than we have now and you know that probably more than 50 percent is where we will eventually need to be but but working towards that number is is is tough I think the other thing that's happened is because Medicaid went in first the providers have had to take on the risk for those programs and it may make them more hesitant to take on the commercial risk where you know there's more money and and a little bit more risk and then I do think that there is a fundamental difference between Medicaid as a payer and commercial payers we really are looking at ways to get savings back to our members if there are any and some of that is because you know because of the cost shift we pay more than everyone else for the same services we want our members to benefit if there are some efficiencies and savings that could be realized through these payments and so we do need to have a mechanism to make that happen so that's a little bit I don't think I gave you a number and it's a little bit of a roundabout answer but that's what we're thinking about you you might be smarter for you to set a number for us rather than we set a number for you the I want to follow up on where you were going there on the cost shift I do worry about that if we are successful in this effort and it's a very complicated effort it's 20 percent of the remote economy and what we're all trying to do is is a heavy lift but if we do if we are successful and we are starting to see savings in the systems you know I worry that those savings get siphoned off either through I think what I believe either through the cost shift which I can see in the state budget process I can see it or my phone is ringing in the background I apologize for that I'm not going to answer it or as Doug Hoffer kind of believes it's an issue of kind of the monopolistic practices of the of the UVM network either way it's the result is a siphoning of savings that is achieved out of the system so do you have any take on whether or not the structural problem here is a cost shift where by the where the public payers are just not paying their fair share or that it is at the monopolistic practices of the largest you know 50 percent of the healthcare dollar in Vermont because it kind of makes a difference as to if you're trying to preserve these savings for your customers for as you say push it back down you know to your premium payers you know what's the strategy is it to to focus on the UVM medical center network or is it to focus on diva to pay pay more of their fair share of the cost of that of Medicaid where you know what are the other places that the savings could go what we want is to see in our contracts and in our arrangements either through one carer directly with the provider a mechanism for our members to see the savings so we want to test them you know specific guarantees that if there are savings some of it comes back to our members and then it won't matter as much what the other sort of theories you have are about where where savings could go but we need to protect our members in their intro so you're breaking up a little bit on that answer um sorry so if you could summarize it again quickly what we need to do in our in our agreements with one care and with the provider is ensure that the money can't the savings can't all excite them to us in some other direction it doesn't matter which one it is we need to ensure that some of it comes back to our members so so that's what we're our focus is um and that's all I have and I've uh you know your responses to Jess and Robin have been helpful as well thank you thank you Tom throw a couple quick questions at you on the uh maybe we could expand the discussion on the passport program or the gold card and could you tell us um what percentage of previously required prior us are now um being um eliminated by this program and what are the standards for um allowing someone to um receive the passport or the the gold card as a provider I'm glad that it's only on advanced imaging so far that's where we started um and what we did and I sort of hold the numbers in front of me we looked at the percentage of a provider's PAs that were um approved in the past three years and we can't it's in the 90s but say ex provider um you know 95 percent or more of their prior authorizations are always approved so we looked at different levels and we have three tiers um sort of the first tier um if they're in and maybe it's even as high as 97 percent 97 percent thank you Lou and if you want to jump in Lou you you might have no more the details here than I do but um so those those providers um we're we didn't eliminate all of the um administration because we still need to see what they're doing um in order to evaluate the program so we require them to put some information in but there's no approval process that automatically um is approved um the second tier is it 90 to 97 90 95 95 to 97 so that's the second tier and it required a little bit more information from the provider but still almost always authorized and then the third tier is the normal process so um do you know Lou the percentages that we've seen if you're asking the percentage of providers who have some level of waiver it's a very small percent um I would I have to dig up the numbers to give you an exact but it's not a huge swath of our network unfortunately um and it's something we do want to expand but we are going to need to have some years of non-covid you know utilization for it to allow us I think he said we're reevaluating at the end of 2022 um and Chair Mullin I think you asked sort of what measures were used so there are clinical criteria for every advanced imaging study and then if an authorization request comes in it either meets or doesn't meet those criteria so the denial rates that we're looking at where they need to be three percent or less for the first tier five percent or less for the second um we're really looking at how did the how do the ordering providers measure up against those objective national criteria um so it's not we're not creating some sort of evaluation process we're relying on on what's already out there through our advanced imaging partner aim I hope that answered your question it does um do you have plans to expand beyond imaging and I'm curious if you've had any conversations with your um pharmacy manager about possibly doing anything on the pharmacy side um I don't know if we're looking at beyond imaging once you leave imaging um then the work really falls to us so that we've got a much higher volume of throughput then for the advanced imaging so I would need to see if we've got any plans in the work Grace or or Sarah I don't know of any I think the work is typically yeah and the work is typically more commonly looking at every year looking at those services that hit the prior authorization requirement list to see what can be shed from that and what can be eliminated and then if there are any new things that have to be added which really doesn't get to the heart of trying to reduce the burden of the prior authorizations but you know not to put too fine a point on it the PA programs are in place because they do save money um not every provider practices in the same way so that there's just not sort of this standard approach on how care is being provided and what services are being ordered so our employers rely on the fact that we do have a robust PA program in place with as light a touch as possible for the provider but we have them in place because they save us money and you know that there there are services that are being ordered that don't meet don't rise to medical necessities so you know I don't know that we would ever strip them away entirely but we do annually look at it okay on care coordination you talked about it and certainly care coordination is central to any successful effort do you have thoughts on how to better coordinate care coordination and if there should be a state group and how you would envision that being comprised to try to really make it more central to a lot of the decisions I believe it is as simple as bringing all of the providers of care coordination to the table to have a discussion to understand where there's duplication of effort and where we can minimize that duplication of effort and where we can partner and if we're doing more care coordination for you know diabetic patients with and producing better outcomes then perhaps we take the lead with that particular patient population but it is all about and this is this is where reform this is the only way reform is going to succeed is getting all of the right people to the table and having a conversation and working together to put a statewide plan in place you mentioned the incredible efforts of the blueprint for health and how foundational that is and that's now under the office of the director of healthcare reform should there be a coordinated effort by that office to bring everybody together is it something that maybe we should be asking Susan to reach out to Ena Bacchus to try to get something going absolutely and and we will do everything you know everything we can to help support Ena and the blueprint to make this happen yeah and I think it's important to remember this what I'm about to say often gets lost in the shuffle that no matter how much we might want to have different entities perform care coordination care management all of us have our own regulatory or accreditation requirements that can't be put aside so and it's not just blue cross under 903 and mcqa but the hospitals might also have accreditation requirements around care coordination that they can't sort of let go of there may be opportunities for some level of light delegation but I think we just need to remember that we all have requirements that can't be entirely put aside as we look at how best to crack this nut and they shouldn't be the overarching drivers of any decisions we make but they do need to be set out loud and remembered as we try to find what is the best way to do this for our members for Vermonters and for the providers and Lou just to push back on your answer on the prior us has there been any type of analysis that any economic modeling that actually measures the costs that the providers are putting in place you know this has been an issue that's been talked about for the last 30 years and you know you hear from providers how they have to have the fancy headsets for their staff because they're always on hold on a call trying to get a prior off and do this and that I'm just curious you you're emphatic in your statement that it saves money but I'm just worried about whether or not all those costs that providers are building in is getting factored into that cost saving analysis or is it just the cost that you believe you're saving for the the employers that you're managing the insurance for yeah you raised a good point certainly our analysis is not taking into account the provider abrasion and so for any hospital systems or providers that are listening their their hackles are probably going up right now we do acknowledge that there are costs associated with that the only work I know around it that that has been shared with me not at a granular level has been with the university of vermont health network as we have worked with them to find creative ways to lessen burdens on the prior off process they have shared with me that they've got a pretty extensive team that has to manage the pa process for all of their contracts you know that span two states so I think that they're a good example of probably tracking and trending what their what they need to put out to support the insurance process not the blue cross process not the mvp process but all of us collectively I'm sure other hospitals probably have tracked and trended it's not something that they've shared with me personally and we certainly are aware of the burdens that really rest with the smaller independent practitioners who might not have that same level of infrastructure so I think that in the back of our mind it doesn't come to the forefront in our own analysis at all certainly because that's just not information that we have to include into our return on investments but that is why we do need to look at our lists on a regular basis what can be shed what can be assumed and you know I I don't know how to get away from them entirely you know that that would be that would be another sort of statewide effort that would have to go into it I don't think there's a simple answer on that one cheer mollum thanks I do think that the tiered approach if you're giving that passport to people that exhibited good practices is an incentive for people to further exhibit good practices and it's a start and hopefully we can build from there so thank you for that effort I realize that we've gone past the time that we had originally planned just for blue cross but we do have to get the mvp as well but before we do that I will open it up for public comment on blue crosses presentation today and it's been a fascinating discussion and if we had more time I think we could keep talking for the rest of the morning but members of the public does any member of the public wish to offer a public comment at this time and I see that Cynthia Browning has her hand up Cynthia thank you I hope you can hear me my question concerns a flexible perspective payment plan and this teach out was discussing we should call it a hybrid since it does have the reconciliation and I may have missed it but do you have any information about the nature of the reconciliation to the claims and fee for service at the end of the year do you end up making higher payments or lower payments are there changes in the quantity of tests offered I didn't hear anything about that and even though this is a hybrid it seemed to me that the question of changes in cost or quantity of care would be important and I acknowledged that it was during covid right so they're all great questions and I think the experience the financial experience has been in both directions to be honest because it was done during covid and then post covid so I don't have the exact numbers in front of me I can't give you those and then we are working through one care to evaluate the quality for patients and so that might be something that we have to get back to you on but but they are great questions I'm sorry I don't have a full answer for you right now very understandable I understand that complexity and incompleteness of the data I just wanted I just wanted to raise that question thank you very much thank you said the other public comment is there other public comment hearing none I wish to thank the group from blue cross blue shield and again a fascinating discussion and thank you for spending your valuable time with us we appreciate it with that I'm going to transition over to MVP and I'm not sure who from MVP is going to coordinate but whoever it is if you could introduce yourself and the rest of your team oh good morning chair Mullen and members of the board first I want to thank I thank all of you for the opportunity to discuss MVP's perspective and experience on this important topic my name's Scott Mamro I'm the vice president for network strategy and strategic relationship management for MVP healthcare my colleague Matthew McKinnon will also be presenting this morning Matthew is vice president network management and MVP and collectively our teams work with our provider partners to manage you know strategy relationships execution of the innovative payment models we're also joined today by two of our medical directors Dr. Jason Rola and Dr. Adam Coonan who actually is based in Vermont practice still practices in Vermont as well as our government affairs staff Jordan SD is here representing that team so they'll be here to answer board questions and manage any follow-up so I'll go ahead and share the deck if we're ready to go great thank you can you see this the slide okay we can okay here we go so let's see I'm going to try to advance it and see how well this works on our side there we go so we've prepared the following agenda today based on the information received from board member Barrett inviting us today we're asked to speak on types of payment reform projects that we've been working on issues on cost containment barriers a fixed perspective payments and ways to move forward and accelerate so we framed our agenda to first talk about our vision talk about our experience and the current landscape and alternate payment models we're pretty excited about the primary care capitation model that we launched in eastern New York in 2021 so we'll highlight that and lessons learned talk about our roadmap and discussions current discussions with OneCare Vermont related to payment reform and then of course the cost containment initiatives and Matthew McKinnon will be covering that topic so I'll start with our mission you know our mission at MVP is to create and sustain healthy communities and our goal is to grow business through innovations that put the needs of our members first so going left to right you know and partners we look for providers and health system partners with aligned mindset and values we strive to provide members with a differentiated experience and care that works how when and where it's needed we believe a key to the payment reform is provider inspired collaboration in conjunction you know with our thoughts ideas and frameworks we believe that's such a critical path for successful payment reform as it relates to our solutions in the middle you know we understand they must meet both member and provider needs to be successful that's the trick to really drive value you know for example offering competitive reimbursement while balancing affordability for members and we know we need to be flexible and innovative you know when we work on these types of models with our partners we consider readiness you know from the mindset the commitment as well as operational and really think about that impact that we're trying to achieve and not to just get into an arrangement as the end goal but really to drive that impact you know there are other plans throughout the country that have a one-size-fits-all model we realize as a regional not-for-profit plan that developing these models really requires that collaboration that learning the iteration you know for success and then finally under empower we strive to provide integrated proactive and targeted information and tools to support decision making I you know was listening intently to the conversation about data analytics information earlier and I think it's it's certainly an opportunity for all of us in fact MVP is currently pursuing a better analytics platform and it's not just the platform it's not just reporting static reports it's how do you bring that clinical information marry it with the claims data provide insights for the providers as well as one care as well as the payers and make sure that information is getting where it needs to be usually in the provider's workflow in a timely basis so it's actionable and I think that's a pretty significant challenge to move from that static reporting to that workflow driven actionable information so I'll move on to the next slide so this is you know a bit about the landscape and New York and Vermont you know we've engaged in alternate payment models for decade you know over a decade you could see the the laundry list here from paper for performance to shared savings to risk to capitation innovation funding this is this is typically in the form of provider partners coming to us with innovative ideas programs new models of care where they're seeking funding so we typically pilot those with them and and try to invest to better understand with those experiments if it's something that we can all learn from as well as bundled payments you know we have programs of various provider organizations including acos and both New York and Vermont across all lines of business I think you're well aware that we have a long-standing arrangement with the Adirondacks ACO that dates back to 2010 and as noted earlier you know we entered into the agreement with one care of Vermont in 2020 working on the commercial insurance programs you know our focus is on promoting that accountability for coordination of patient care investment in primary care infrastructure with an expectation you know that there'll be an improvement in quality and efficient utilization of services as a result um through these these programs you know I we share the sentiment of of some of the board members we've heard speak earlier that we're focused on moving away from fee for service volume model to population health management payment approaches that really help identify target stratify at risk segments of the total population and help us achieve our our cost objectives you know we've we've paid millions of dollars sometimes annually as a result of improved outcomes quality cost so on and so forth it is important to note you know covid has come up in the prior conversation and I do need to footnote that here that it's important to note that um some of our provider partners in New York um and and Vermont to an extent have paused their participation in alternate payment models in 2020 and 2021 or delayed their glide path towards progression for example from shared savings to shared risk or to to to capitation due to uncertainty as it relates to um trend member utilization complexities of target setting with the actuaries during the pandemic um so our numbers as of today approximately 26 percent of our total membership is under an alternate payment model um and and that corresponds to 20 percent of the total medical's expense expenditure um you know but we're continuing to work to reinvigorate those conversations and move forward in in new ways as we you know based on our learnings from the the pandemic so on this slide um five we have some some examples um you know starting at the top left uh pay for performance um I know you're well aware of the Adirondacks ACO all payer ACO model includes um seven commercial payers including MVP um the ACO has paid a PMPM amount to coordinate patient care and invest in infrastructure uh and through our arrangement they have the ability to earn additional dollars based on quality performance um shared savings to advance the member experience and quality and efficiency um you know we do have shared savings contracts under which providers um can can share in the savings if they hit the the financial target medical expense target um as an example that's the the type of arrangement we have with OneCare Vermont currently um you know starting in 2022 for excuse me 2020 for small group and individual members um as a result of this arrangement actually OneCare Vermont received uh $850,000 in shared savings in their first contract year based on performance um I also wanted to note that MVP has engaged especially in New York state many of our FQHC providers and value-based uh payment arrangements and through our participation in uh the the the district goals that set that were set by New York state for Medicaid um in fact we have approximately 40,000 members and shared savings or shared risk arrangements with FQHCs and and and our network in New York um and are very interested in thinking about how that expands and translates into Vermont um shared risk um MVP is is is currently in um and shared risk arrangements for example we have a Medicare Advantage uh arrangement with the University of Rochester Medical Center um one of the nation's leading academic medical centers um you know they have provider network of over 2,000 um community um lives uh uh I'm sorry providers located throughout the Rochester surrounding areas with six hospitals um Cancer Center or uh Oral Health Center Home Care Assisted Living Urgent Care Extensive Primary Care Network and we have a significant um shared risk arrangement in place where the provider share in savings um if they hit their target or share in risk uh should the expenses be greater than their their target as it relates to capitation you know we've been involved in a variety of um capitated capitated arrangements over the years um we have a long history in the mid Hudson region of New York state um with capitation especially uh with with Medicaid uh line of business um primary care we've also we have capitated arrangements for dental care lab services skilled nursing home home health um we actually have recently entered into a joint venture uh for global capitation for dual eligible special needs plan members or DSNIP members um the new organization was created to provide specialized care and RAP services for those those dual eligible beneficiaries for both Medicare and Medicaid um and I'll talk a little bit more about this on the next slide but we recently launched an enhanced primary care model um and in eastern New York in the greater capital region and I'll talk about that shortly um a few other notes we also I meant I talked about that innovation funding um so in partnership with an IPA in New York we implemented uh MVMA we implemented um an innovation excellence program that was designed to reward participating providers that have identified areas of improvement in their practice that will positively impact that member experience have designed a unique or innovative program and um have implemented or in the process of implementing that program um the programs have to have measurable goals and they need the to have the ability to report on progress throughout the year um we have tiered funding levels and this this this is available to all of the IPA participating providers with MVMA and we've seen a lot of success a lot of goodwill and a lot of excitement around that that initiative um we also uh have bundled uh payment arrangements um for example total joint replacement in complex cases of end stage renal disease chronic kidney disease so moving on to the next slide I'm gonna talk a little bit about um our new primary care model um so in 2020 uh when the pandemic really really hit in the spring we had many conversations with our provider partners about what's happening during the pandemic about cash flow about payment models um and we really listened we looked at the data and we moved ahead with this model in 2021 um you know and and I think it's not lost on this group that um they were interested in and predictable cash flow um to help with with with optimal practice management um but they also were interested in how can they focus on quality how how can they focus on team-based care with the new payment mechanism and really pave the way for other virtual care options or other experimental interventions rather than focusing on that that volume um you know goals of the model were to support that that innovation and and quite honestly discretion in the way um the providers were offering services and intervention resources to meet the holistic needs of members um we we we heard through our member data that it's really important right to promote member access um to evolving forms of interaction you know we we're uh tele-medicine and and beyond and they really continue to drive that improvement um the model's a a tiered capitation model with rates that are specific to um patient cohorts and you know age demographics lines of business um the practices are scored prior to the beginning of the measurement year against performance metrics if you look at the picture on the right hand side the measures all map to three core dimensions of either access population health or member navigation and you can see in the outermost ring examples of the types of um metrics we're using to evaluate provider performance and and and help them improve in those areas that are really critical for our our member experience um so we swiftly rolled it out we have 25 000 members uh engaged in that that greater capital region in eastern new york um representing 14 independent practices and five hospital systems um that that got involved um in 2021 um so some notes on the rollout some lessons learned you know provider engagement was interesting around this and working in partnership with the IPA was so critical to having all these discussions it started with education um reviewing the metrics the philosophy we offered substantiation for why each of these dimensions were selected and how it's meaningful and adds value we provided each group details around their scoring um you know there were there were discussions where they they had a lot of interest and curiosity around the the data um and you know if a practice was in for example tier one and they're interested in moving to tier two we gave them specifics and tried to be as um point out insights and areas that are actionable to help them move on that journey um towards that higher um that reimbursement model and we continue to discuss ongoing performance and support um you know for the implementation part of this um one of the key messages we heard as we were doing our listening tour was the model has to be simple and it has to be easy to implement you know they kept reminding us we're busy seeing patients with covid we're trying to get our practices back on track um we're we're really trying to understand how we can do this without significantly placing a new administrative burden uh on our practices um so we we kept that on mind and and worked really tirelessly to enable providers to a smooth transition um for instance um we we required no changes at all encoding or billing to move to implement this model on on their side um you know we have a monthly capitated payment that's calculated using the attribution methodology um against their provider roster um and then we we we have uh transparent reporting to the practices on a monthly basis so that their their either their clinical team or you know their financial teams can have direct access to that information um and review it um they receive their capitated payments um and you know attribution is tricky um as you're rolling out new models you need some flexibility you need to be able to learn and work with them um and you know we have conversations around making sure they're receiving the correct fee for service payments for any care provided to members that are not attributed to their practice in the cap model and making sure that that continues um and the other piece of this that I believe our colleagues at at at um Blue Cross mentioned is you know complete and accurate coding is still critical we still need those claims for quality for HEDIS type reporting those types of things um it's also used for attribution it's it's used for risk coding it's used for identification for care management so we still need that that that that that reporting to move on to the next slide here let me click on this there we go so you know this slide is intended to share more about where we're at um and and our and our journey in Vermont and and in our discussions with one care of Vermont in particular um you know MVP and OneCare have had discussions since we um engaged in earnest back in 2019 working towards that um that that agreement year of 2020 the total cost of of care shared savings arrangement um so you know we we we have talked about the fixed prospective payments target um back to those original conversations and I actually think chair mullen you can attest to that we you were a participant in those early conversations to help us get off and thank you for that uh underway with with OneCare um you know what we're what we're looking to do with OneCare Vermont is um move towards shared risk with a target of 2023 um both parties are are very interested in um bringing that primary care capitation model um in and ideally 2023 um there's some nuances with that you know MVP has a model that's very similar to the existing cpr model the existing comprehensive payment reform model um you know where it's a fixed payment differentiated by patient age and demographics and there's there's a set of primary care services we try to minimize the exclusions for operational efficiency um however the one difference we need to talk through is unlike MVP's model we we where we directly pay the participating practices um and and in the model with OneCare there would be a fixed rate monthly that would go to OneCare and OneCare would then reimburse all of the practices downstream um so we would need to talk through the mechanics of the model the efficiency the administrative tasks and and make sure that we're not adding any unnecessary um administrative burden uh or or extra delays in the information flow um so what what I'll share is you know our operations team at MVP our strategy team our network management teams are actively meeting with OneCare in fact the next meeting is on on on May 2nd um and actively talking about how to move towards the fixed prospective payments um you know we have the exploration of 2024 we know that um if you look at the bottom there's some keys to really standing that up successfully and we're also keenly listening to our colleagues uh Blue Cross Blue Shield of Vermont and hearing their lessons learned as you try to move in that direction um I will share with you that MVP philosophically would love to see this become a pure global capitation fixed perspective payment um understanding that um there may need to be some discussions around synthetic cap or or um reconciliation but ideally our ideal is to that that that true global cap um so that's what we're trying to strive for a philosophically um in in those in those conversations um we anticipate as we move through our agreement discussions with OneCare Vermont having a better understanding of the model and specs and targets and things this this um late this summer um early fall um based on strategic alignment and operational feasibility um so in the bottom you know key operational capabilities and I think we heard these touched upon earlier right flexible attribution um and and what we mean by that is not just the the logic but how the logic is coded into the reporting systems into our claim system all of those components so we understand how the attribution is working and we have a way in in our model to learn as we move through this with the with the with the partners and and as you all know it gets more complicated when you're talking about hospital attribution when you're talking about specialist attribution as opposed to primary care attribution so that's where some of those flexibilities are key and that's on our roadmap to continue to advance that um I already mentioned analytics high value care insights and analytics it's so critical to having those more advanced analytics to support these types of models to really support the providers that are moving in this direction so we do it we have the information together um and I do think again it comes back to blending the claims data with the clinical data and the EHRs and how that information is available I think I heard earlier um it's not you know the goal isn't to overburden providers with just reams of paper reports right where they sift through all the raw data but to really think about what's truly actionable and what's important for the finance team what's important for the clinical team and you know the quality folks versus care management care coordination and on and on so that we get the right information to the right people in a way that it's trusted and and we're not reinventing the wheel to to steal the phrase that I heard earlier um and then operationalizing the fixed perspective payments I don't want to oversimplify this um this is something we're looking very carefully at um as it relates to business processes to systems work to IT configuration testing all of those components it's not just the work on our side it's the work on the provider side too so we're working through all that to better understand what that plan would look like and you can see on the right hand side some considerations and barriers um simplicity you know in our conversations and initial exploratory conversations around this we're hearing the administrative complexity and challenges um and the expense um is something that providers are really thoughtful about as far as how this would work um I think the other thing that we we've heard is you know buy in as it relates to the perception of fair payments so you know I think um those of us on the payer side have been in meetings where you have our actuaries and actuaries representing the provider systems and boy those are fascinating conversations trying to get the actuaries to agree on baseline assumptions moving all the way through to those those more complicated calculations that you arrive at so that's something we're trying to think through and I don't have a magic answer to that but how do we really work through that so that there's trust and and in order to move to that true global cap and I think it's trust its experience you have to get started um and then I've already touched on the operational readiness so at this point I'm gonna hand the the deck over to my colleague Matthew McKinnon to touch on the cost containment strategies Matthew thanks Scott good morning again this is Matt McKinnon vice president of network for MVP and one of the things under cost containment that MVP did about five years ago is we decided to join forces of network and medical Dr. Morolla who's on this morning him and I actually co-chair MVP's total medical expense committee we have representation from all the departments of MVP with a focus on our cost payment cost containment strategies that will benefit our members can reduce premium dollars and so forth so I'm just going to touch base on some of them for 2022 and what's in the pipeline coming coming up one of and these are all specifically focused on Vermont and the numbers that we're reporting here are specific Vermont savings so one of the first ones we did was the termination of our agreement with multi-plan we felt that the rental network wasn't getting the savings that we could get directly by either defaulting to fair health rates or actually doing direct negotiations for out of network services and determining if it is a provider that's treating a member on a regular basis do we need to bring in plan and so forth so so reducing those network lending fees and so forth was over about a million dollar savings the next one next initiative we're working on is an implant pricing we're actually going to have policies that update to limit implants to pay an invoice cost and that's going to obtain us about 350,000 dollars in savings what we've heard in the earlier presentation is always looking at our pharmacy 2022 formulary changes will result in about 300,000 worth of savings and you're actually going to see for 2023 we also have material changes that will get us over a million dollars projected and just as an FYI MVP will be going out to bid looking at our pharmacy benefit manager for 2024 so we think that's going to be imperative over the next 18 months to really challenge our existing pharmacy benefit manager and see what else is available to the benefit of our members you know there's a real focus on the safety the quality the efficient utilization and the cost for the members when we when we look at all these various initiatives and approve at the committee level as to what is going to be the impact what is the impact of the member to our providers our provider panel etc last one is always ongoing on coding initiatives you know focused on evidence-based best practices how can we specifically look at updated policies look at various payment methodologies inclusive services to primary services and so forth so we have about 100 over 150,000 dollars of savings for this category and then in the pipeline there was discussion earlier about lab management one of the things MVP has done over the years and I've overseen this with our lab management is we have a very limited lab panel we definitely take a look at you know especially especially with COVID a lot of these labs that have been popping up and really working in partnership with our labs that are currently contracted with us and you know again quality of services and also steering utilization to get the price best pricing and so forth and one of the things we've done over the last few years is challenging panel testing in what's part of a panel testing and getting to the specifics but we're also looking to move forward into lab management looking at Avalon is one of the partners that we may move forward with clinical editing as I discussed is a continued thing that we in combination with medical are always looking at as well as coding and billing initiatives so again you know Dr. Morella Jason and I really get excited about sharing this committee working with the other departments within the organization and be able to you know share these cost contaminants back to the members and I believe that is all our slides Scott if you advance to the next we'll definitely open it up now for questions. Well great thank you very much and for this round we'll start with a board member lunch Robin. Great thank you thanks so much for the update it was great to hear about the work that you're doing particularly around the primary care capitation model and with one care Vermont. I'm wondering if you could talk a little bit in the primary care model if you've thought about or started working with the blueprint for health in order to think about how your model interacts with both one cares model but also the blueprint for health which is the state's advanced practice multi payer primary care initiative. We have not had that direct conversation yet board member lunch however I do actually have a note to talk to our colleague by the name of Carla renders who interfaces more with that program Carla renders is also our point person on the one care conversations so I think we will be sure to take a note and follow up to see if there's an opportunity. Great thank you and I was also wondering if you could speak a little bit to the Medicare Advantage plan that you have started with UVM Health Network. Sure do you have a specific question. Well we just haven't really had the opportunity to learn about the program from your perspective and certainly we've heard you know read what we've read in the news and heard a little bit from UVM's perspective but I just be interested in your perspective on you know how why you as a company saw that as an opportunity and the role of Medicare Advantage in Vermont's marketplace and also in health care reform. Yeah so so you know we feel that the Medicare Advantage plans complement and actually amplify the ongoing movement towards value based care you know in transformation with those same aims of approving patient health and controlling costs um our our partnership um what was founded on those core values and principles that we spoke about earlier um in earlier conversations uh with the the health network we talked about not for profit we talked about our experience in Vermont as well as in New York we talked about our mutual goals um to really have a successful launch and to really make how can we make the biggest impact on on health and and part of it is through as many covered lives as as as possible um I think we're very much of of like mind that we're very interested in a a a payer and a provider aligned experience and in early on in those conversations we talked about our philosophies and and they shared their philosophies and they were surprisingly similar you know when we started to talk about our missions and and the health of the communities we serve and the opportunity with Medicare Advantage and we looked at the the penetration of Medicare Advantage in the state of Vermont compared to to the rest of the nation so there's more opportunity in Vermont in Vermont with with lower penetration um we looked at how could we have a differentiated experience that's really informed and by what they do well and what we do well and having those candid transparent conversations with with each other we're very pleased with the with the launch where it where it where it target um you know and um now what we're looking at is how do we do the things we talked about to really enable um impact and success as it relates to sharing information as it relates to um payer and provider collaboration around benefit design how how do we look at improving um quality how do we look at care management we've talked about care management earlier you know the spirit of that conversation has been who's best equipped to truly manage the care of those patients now I do want to acknowledge what Lou said we we do have to pay attention to the regulations and ncqa certification and all of those obligations but we're trying to think about new and innovative ways to do that to reduce that duplication so just just wanted to share um those those aspects and you know um one of the things that we're seeing as we look at net promoter scores and consumer experience in new york because we have a deep um medicare advantage history in new york and we've seen very high net promoter scores for the seniors in new york and we're very interested in bringing that experience to the vermonters that are enrolling in that product thank you um do you see a role a complementary role uh for aco programs and medicare advantage programs working together you know I I think it's it's everyone is willing to do the hard work right to to really move towards that risk and do things in an impactful way we're trying to figure out a way to do so without really shocking the system at a time um we're we're we're we're still in the pandemic unfortunately um and and I think you know where there's an opportunity is one care of vermont is a fantastic table an opportunity for collaboration um and what what i'll say is um we we want to think about how we can um as we bring in more lives right how do we bring in more accountable providers that are willing to share in that risk and participate in ways that we don't violate you know stark regulations so on and so forth but we're very open and interested in that thank you um i'll leave my questions there thanks thank you rob and next we'll turn to board member pelham tom uh thank you thank you um just a couple of questions uh similar similarly to my question for uh at blue cross blue blue cross blue shield is um on your slide uh I think it was slide uh seven you have fpp explore in 2024 um and I'm just wondering if you have in mind as you engage in this exploration a a percentage of your payments uh that that that you would need to achieve um to get to to to get the efficiencies that a fixed but prospective payment is alleged to um um off of the system I mean is there 30 50 percent what what would your target be uh um member pelham I I can't speak to a target at this time but we would be willing to take that back um the information you shared when you posed that question was incredibly helpful in the first time I personally heard those numbers um so I'd like to take that information back and think about that with our team and and have a thoughtful response okay thank you and then this is a question that um uh always floats around in the back of my mind and so I maybe there is no answer in this forum but I'm going to ask it anyhow um sometimes I wonder whether or not the uh you know so so for the public payers um prices for procedures are are pretty well known I mean they're they're established and they apply across the board but that's not true for the commercial payers and uh so our staff recently took a look using um vcures data and discharge data you know for I think it was like 60 procedures and the variation in in payments to different providers um uh by by the different payers now just to give you some examples um you know there's and this these examples are from a couple of people that have complained about what they get paid but for the procedure was obstetrical ultrasound of fetus and the matri health care for women uh were paid 184 for that procedure um and the number of episodes here are statistically significant in that case it was 306 UVM medical center was paid 437 dollars central Vermont medical center was paid as a median these are median numbers median of 750 dollars and Porter was paid 405 um similar variations for transvaginal ultrasound first trimester and transvaginal ultrasound and non-obstructed echocardiograms um the Champlain Valley cardiologists associates were paid 322 dollars and the UVM medical center was paid 2166 dollars central Vermont 1,948 and Porter 1,541 and so I sometimes wonder whether or not these relationships that have between the commercial insurers and providers that have developed over time um are are uh are the status quo and glue that hold that system kind of in in in in relation with one another and whether fixed and whether the movement to fix prospective payments might affect those uh market-based relationships over procedure costs where there's such a wide variation um across them um so I know that's not a well framed question but if you know but if you see where I'm getting at it's it's the the public payers it's all pretty known uh for the private payers you know for the commercial payers when we kind of look at the data it's all over the place and uh and to my sense some of the complaints that people make seem valid to me. Matthew would you like to? Yes so I definitely definitely agree uh with the statements made and I do think over the next two years as even MVP has has developed our own department to start looking at the specific transparency it is going to help get things in line and we are actively you know through through our network through our transparency department even with our sales department and our our um clients as far as our employers and brokers you know looking at how this transparency is going to allow us to educate our members better and take a look at how do we close the gap on that pricing differential so I think there you know there's definitely going to be a lot more to come with that and I know not a specific question but it's something um actually my boss and I Karla Austin the CFO this is the one thing keeping us up at night is the transparency and and making and we think it's to the benefit we think it's definitely to the benefit of our of our members and something that we're going to be tackling uh you know in the front line in the next you know 12 to 16 months and we'll keep you posted on those efforts and how we can close those gaps if I could just thank you for that I I suggest that you might want to go to our website and look at is the name of the report is the uh reimburse reimbursement variation report and it covers about 60 different procedures in very uh in detail by by each of the payers Medicare Medicaid and and commercial payers and it's just it's the kind of thing you look at and you say to yourself how does this happen you know I mean why why is this the way the world is right now and I don't have an answer for it but I sometimes worry that these market-based relationships that have developed over the year are a hindrance uh to transitioning to reform so those are my two questions and uh uh I'll pass it along to uh the chair I guess and just real quick Dr. Cooner did you want to add something from MVP yeah no I I'm a very aware of these um inequities as well because I've worked in private practice as a cardiologist and of course as a hospital employed cardiologist and I think it's also a health equity issue because patients end up paying a portion of this so I think this is a high priority and even though what we are in an uh an agreement with UVM the UVM health advantage program is for all Vermonters and it's the the distribution of members is spread all around the state of Vermont and of course upstate New York so I couldn't agree with you more um and I've seen it from you know now three viewpoints private practice uh hospital employee practice and now working for a health plan so I'm very interested in reading your report and and any way that I can help to tackle this I'm very interested well I I kind of uh when I first encountered this data I kind of hit the road and talked to some of these uh and most of them the independent providers are at the low end of the payment scale and it just uh you know breaks your heart there's people that are doing what they think they what they want to do and doing it in good faith and you find these uh thousand percent more than thousand percent differentials in terms of what they get paid and it's uh I I'm just hoping that as we move through um a health care reform that somehow the fixed perspective payment system will will kind of level the landscape so thank you for that okay next we'll turn to board member hauls jessica great thank you so much and I think in the interest of time we'll just ask a couple questions I know we're going way over um so but thank you for the presentation it's nice to meet you all and see you all um you obviously you have a pretty strong footprint now in two states you know obviously both New York and Vermont and you have experience in New York with various different um value-based payment models and I'm wondering what you see as the key criteria that in your experience you've observed that providers or a network of providers through an ACO must have to successfully transition to a true risk-sharing value-based payment arrangement are there key criteria that you see that they must have it's a it's a great question um member homes um you know like our colleagues at at Blue Cross we've seen successful engagements programs and we've seen others we've learned from um in in fact some of our greatest lessons learned came from our experience in in New York under that district model where the state had a very prescriptive percentage of arrangements and member lives and Medicaid that had to be under a level one I'm using New York state's risk levels now a level one shared savings a level two shared risk and even they were trying to move toward that full global cap if they could and those those those more innovative arrangements I can tell you um that um there's there's some some three you know key criteria the first is really a commitment on both sides starting at the top at the executive level but all the way being communicated and effectively brought all the way down we've been more successful in the arrangements you know in quality and hitting total cost of care targets and so on and so forth where we have very active um joint operating committees where executives from both sides are committed and in conversations and participating and having those relationships and building that trust is is so critical um the other piece of it is going back to the data information analytics you know you really need to collaboratively work on that not overwhelm them but be as transparent as possible with the information um when we're in risk arrangements we're willing to share that claims data and our ask in return is that they share that clinical data with us and what we're trying to do is um create a vehicle where we can marry that information share that data um share it in the provider workflows to get those insights out so that we're not only um giving a gaps in care for quality for example report we're trying to figure out how do we serve that up in in in that pre-planning section of the EHR how do we serve that up when that when that member is going to be seen in that practice so they have the best opportunity to close that gap how do we streamline the reporting back to HEDIS you know so that we're not sending an army of people to collect charts out of a practice and disrupt their practice how do we make that information flow more efficiently and how do we bring those um total medical expense those insights that Dr. Merola and Matthew were speaking about earlier make them available to them how do we partner on their initiatives you know where they're focused on improving quality and doing something innovative with care coordination so it's that flexibility that willingness to partner that willingness to think about things in a disruptive new way and say you know what maybe they are better equipped to do this than we are let's figure that out and see if we can change that mindset to how we how we truly collaborate so it's that trust that executive commitment it's that communication it's working on the data and information in order to get that truly impactful you know we've seen arrangements where um that's happened and and it's really meaningful and deep like the u of r relationship that i spoke to um we've seen others where we entered into an arrangement you have quarterly reporting and sometimes the practice wins based on just risk changes it would membership population alone for example with the medicaid roles and other times where they end up owing mvp but you really got to do the work it's not the contract that's just the starting point you really got to do the work to move the dial and you need that commitment to do so so and the other thing that helps is when there's enough lives enough of the mix where for example mvp is an important payer to them and they're really willing to really dive into that as opposed to if we're number seven or eight on their list um you typically aren't going to have that same level of meaningful deep relationship and commitment super helpful i really appreciate that and i'm just wondering actually allowed out here but i wonder if um that working group that might be gathering about care coordination might also gather and respond to you know some of the data sharing and how to optimize data sharing um sounds like similar insights you know are needed um and you've you've got a lot of lessons that you can share as well so i don't know susan i'll just throw that out at you so let me my second question is um as you're moving towards more of these payment models that shift financial risk to the providers which it looks like is on you know your trajectory is is thinking about that how do you then think about your own reserve needs going forward right so we always are clearly giving contributions to reserves to mvp and other insurers but that's because the payers have the financial risk um as you're shifting some of that pay you know that financial risk away how do you think about your reserve needs it's a it's a complicated topic as you as you know member homes around the reserve requirements in some ways the reserve requirements stifle in and gate some of the speed at which we can innovate and enter into different types of arrangements so for example i'll tell you we were in conversations and with a large system in new york a while back um pre pandemic um talking about a joint venture um like a true health plan joint venture and one of the things that we were talking about is not only moving towards that global capitation but how do they get involved in product risk and the actuarial risk and are they willing to bring reserves and share in the reserve requirement with the health plan and what we found is it requires a tremendous amount of education if you're entering into those types of conversations with a provider system because that's not typically what they've had to think about or at least in a different way than we have had to as as payers and you know we're open to those types of arrangements if if if provider systems are willing to truly go all the way to not just the mlr target risk but to go all the way to product risk and to share in the reserve requirements as well as the the risk reward scenario so we're open and and to those types of conversations but it is a complicated factor i'm not uh you know our our cfo and and our finance team would be better equipped to go a little bit deeper than that board member homes but hopefully i answered your question well you did and i just want to make sure that you know as we move towards these fixed perspective payment models that we're not basically you know holding the payers are not holding risk and then we're not all also asking you know risk reserves for the financial risk and then the the providers are also then asking for reserves for the financial risk that they have right because that is going to add cost to the system so we need to think about that as we're moving forward well that the the true in my opinion this just got's opinion the holy grail is you have pure alignment on the shared risk model as well as the product risk model and those ultimate scenarios that's where the the boundaries between providers and payers start to blur and and you've probably have seen some of the literature on what what the the term pay wider models um so we're trying to think about kaiser geisinger those types of organizations and how do you arrive at that endpoint with all of the complications and challenges we've talked about thus far in the in the whole conversation thank you so much i appreciate it that's it for me kevin thanks jason i see that susan keeps popping on screen so i i will give myself the hook and not ask questions in order to try to get us back on uh schedule um so we'll next go to public comment does any member of the public wish to comment on the mvp presentation and synthia browning thank you i would just say uh as a member of the public and a customer or when i hear about aligning the payers and the providers and i hear about the importance of trust between the payers and providers i feel the need to remind you about how important it is for the reminders to trust that situation because the patient has so much less expertise and information than either the payer or the provider and they are very vulnerable it just surveys doesn't cover it because by definition we don't know what care we should have gotten i understand the evidence-based approaches and quality monitoring but i just would say that i'm a little skeptical when the payers and the providers are getting together that they will end up with reduced risk and higher savings at the expense of the people whose care should be coming first it's not a question but i welcome a comment because i wasn't completely reassured by your presentation thank you so thank you for for your your statement and it it's something that we we we truly you know think about which is that what we call the member experience and everything you shared is wrapped up in that that member experience we at mvp do take that member experience incredibly serious it's part of our core values we we do what's called evidence-based innovation surveys where we do talk to our members in vermont and in new york where we get both qualitative and quantitative data information insights including those types of concerns so we can take that information as we think about our benefit design for the plans that we're offering and the other part of this is in order for us to continue to be successful no matter the level of collaboration with the providers we have to offer competitive benefits and and and price that best serves the needs of those members or they're going to move to another competitive plan design so we're hypersensitive to your thoughts we're taking the transparency incredibly seriously as matthew talked about earlier we we we're very serious about um access concerns um and helping our members navigate through that in partnership with those the provider systems and trying to make a more integrated comprehensive approach that said um your your comments and concerns are noted um and and we appreciate your your your your your skepticism and your thoughts as we think about how we can best serve vermonters thank you hey is there other public comment is there other public comment hearing none i want to thank the team from mvp um it's been a great discussion and one that uh could have gone much longer and uh i apologize that i wasn't a little bit more efficient with the uh the team before you but uh it's hard to cut off the discussion when it's uh really uh intriguing people so thanks again and and really uh thank you for uh all the efforts that you've made on value-based care and uh you know trying to uh provide the the best product to uh vermonters so thank you thank you so with that Susan i'll turn it over to you thank you mr chair so i'm going to provide to the board and to the public today an update on the wait times working group that was formed as a result of the f y 23 hospital budget guidance thank you kara kara is going to put my slides up i don't want to experience any technical glitches that we like we had this morning so um i should be brief but i do want to take this time to update all of you i'm just going to go through our progress to date our charge um at the end of this presentation i want to hear from you board members on your priorities um and let me just go through this presentation but just keep that in mind as we're as i update you on what we've done to date so this is the current language um i'll just pull out the key parts of it this language is included in our f y 23 hospital budget guidance as you recall uh we added this language after we heard from um vas and hospitals about the administrative burden of collecting wait times so we took this back um you put in this language and we formed a wait times working group the members of that group include vas they include the vermont department of financial regulation the office of the health care advocate um and other interested parties the charge of the of this working group is to determine alternative metrics for reporting wait times for the f y 23 budget uh by may 2nd of 2022 which is if i recall i think next tuesday maybe it's monday don't quote me on that um and if we this group cannot determine appropriate metrics for this group then the default is what is in the was in is in the f y 23 budget guidance which is and i'll just read these because it's technical that um if the work group is unable to determine appropriate metrics the hospital shall report the following for each hospital-owned practice for each primary care and specialty care as well as the top five most frequent imaging procedures specifically please report for each practice and imaging procedure one referral lag the percentage of appointment scheduled within two days of referral to visit lag the percentage of new patient seen within two weeks one month three months and six months of their scheduling date in each case hospital shall outline steps to resolve wait times so you can go to the next slide kara um before i get into these metrics that we've discussed i want to report that the working group has met three times to date we have another meeting scheduled on thursday of this week and we've discussed discussed several options um these are the things that we've talked about but are not moving forward at this point um we first discussed the option of utilizing the secret shopper data from the wait times report that was um released earlier this year and we were told that we were unable to use that data for this purpose so that came off the table we also talked about va measures veterans affairs measures you can see what they are at this point those are they're they're great measures they're just highly complex and and and just too much of an administrative burden in this shorter time it's something that dfr might consider as they look at wait times in the future and then we also heard from vas on a really a qualitative proposal which we then um you could see the questions there we've actually incorporated those into a dfr proposal so on the next slide kara um these are the metrics that are on the table and i just want to say out loud for i know the board is aware of this but just to bring the public along to the department of financial regulation will is starting their process in looking at wait times it's it was a recommendation out of the wait times report and they've been very very good partners in this work um with us to look at the wait times for this for this year's hospital budget guidance and want to make sure that what we do land on in terms of our hospital budget guidance whether it's the the um default measures or something we agree to in these in this working group is that they will utilize that in their work going forward over the next years in developing um wait times metrics that they will transparently report out so the metrics that we have on the table now are the uh institute for health improvement ihi third next available appointment it's a standard that's um we've collected it in the past we've heard from providers that it's not always the most accurate representation for consumers so it's not perfect but it's still on the table and then i um alluded to this earlier the department of financial regulation has a proposal on the table um and it is both a quantitative with quantitative questions and also has a qualitative assessment section um they are we are as a group have asked them and and the green mountain care board has worked with them to put together some survey um questions and that would really focus on some of the the quantitative questions that we feel um that needs to be part of that assessment so we'll hear from dfr at our working group on thursday and i can i'm happy to report that back to all of you i it's just not ready for prime time today but the working group has seen the initial draft and they are working on an updated draft to include those survey questions as part of their proposal so the next steps are as i mentioned we'll have our meeting this thursday which will be our last meeting since we are um to report back to you on the honor on what we decide if if we can come to a determination of other metrics and then if needed we can bring this up again next wednesday to update you and the public so i think there's one more slide great so i'm going to turn it back to you mr chair and to your board members what i really would like to hear from all of you is your priorities on these wait time metrics as we are finalizing this working group i wanted to check back in with all of you to hear your thoughts so what would be really helpful is to hear thoughts from um board members launch in pelham um jessica has been in on this group uh from the beginning and um has um weighed in quite heavily um tom is our other designee tom walsh um but he is out this week so i'm pinching for him and filled in at the meeting earlier this week and we'll be filling in for him again tomorrow so it would be really helpful if jess and i knew what um you were thinking robin and tom sure i can go ahead and jump in unless you want to tom um go ahead and jump in i'll be close behind you okay um so i i feel flexible and trust um the you know whatever decisions that you two come to in the work group um i do think it's important to have some sort of quantitative metric um so uh you know and certainly we've used third next available in the past so if that makes the most sense to uh you all i'm totally fine with that so i'm not going to get stuck at anything particularly specific but i do think having some sort of quantitative metric is important and then i would certainly qualitative information is always helpful to give the picture behind the numbers but i would um support you know whatever uh makes sense in the in the greater context of what's being discussed so i don't know how helpful that is because i do feel pretty flexible but um and but you know you guys are in the thick of it with the everyone else in the group so i think it's a little bit hard not being involved to to be too you know for at least for me to be too like wedded to any one thing yeah just uh for further information um i think most people agree that third next available um has its faults but one of the pushes has been from um what i would call not so much smaller but yeah kind of smaller hospitals in vermont that they don't have the capacity to do what we're really looking for with their information systems so that's where the push for the third next is coming from i do think that uvm for those three hospitals with the epic system could do um the more detailed information as far as referral lag visitation lag etc um and going into this i had wanted consistency so that everybody was reporting the same way but i'm not so sure if we're going to get that at the end of the day or we'll get information that may not be as helpful as um one would like so well my take on this is um and it's from a distance is that it's not a perfect world and and sometimes you don't get everything you want and um as i look back on this wait times issue you know i i think that dfr uh has handled it responsibly um maybe not perfectly in terms of the shopper report and some of the statistical anomalies they worried about but i think that you know at least as a board member working with other board members that that you have a strong sense of trying to minimize the administrative burden on hospitals but at the same time getting information that's usable and and that does mean information beyond just qualitative and uh so i i trust your judgments to you know to um find that balance and um pretty certain that i'd agree with it every whatever decision you uh that you may ask the question so the trade-off might be as as kevin mentioned consistency so there are some hospitals that are probably able to i think the health network might be one so that'd be three hospitals that might be able to provide the information that we asked for in terms of referral lag and um you know scheduling lag and the distribution of you know two weeks one month three months six months which i think is is more meaningful data um and is particularly in the scheduling um piece of it is more reflective of the true patient experience than third next available so would a outcome that would be uh you'd be amenable to would be those hospitals that can provide the data in the way that was requested should do so and those hospitals that can't you know tell us why and give us the data that they are already collecting which is most likely to be third next available appointment um and any benchmarks that they're using um to benchmark their wait times against would that be uh amenable to all of you if we were to propose that because that it does kevin to your point that's not going to be then necessarily consistent across hospitals but it may be more meaningful for the hospitals that are able to provide the data as we originally asked for it i mean to me it sounds like a practical solution i mean the the network hospitals are 62 percent of the pie and so it's it's not like it's three hospitals versus uh the other 11 um you know what the network can do because they've got a great amount of resources with um with epic you know we should leverage that and then work with the hospital other hospitals to do as best as they can do with what they have to work and that to me is is uh equitable um it might be different but that because of epic the network can do something better probably than the other hospitals but it still would mean that they're both doing the best they can and we did receive a proposal from laws that was forwarded to all members of the board maybe susan you could make sure that gets posted to our website so the public could see that as well sure thank you this is helpful it is helpful and it is um at the noon hour so why don't we um recess the meeting here and come back at one o'clock um nourished and uh ready to go for this afternoon so i'll put this meeting in recess till one o'clock thank you