 Yeah I hope you guys cannot hear me. I have like several fans in the background so. Yeah we can hear you good. I'm just checking Maureen are you on the phone. Parking so I should be in my office in like two minutes. Sorry about my internet was asked. Just wanted to make sure we had everyone here. So good morning everyone. My name is Kevin Mullin chair of the Green Mountain care board and we're about to get started. The first item on the agenda. Is the executive director's report. Susan Barrett. Thank you Mr. Chair. Good morning everyone. I have a few scheduling announcements and then also want to review some public comments sessions that are occurring at the board. So first I want to remind folks that our schedule for July is listed on our website our board meeting schedule. I want to highlight a few items first that on July 19th Monday July 19th we will be hearing from MVP on their rate review requests on for the Qualified Health Plans. That meeting starts at 8 a.m. It is on Teams and all of the information is located on our press release and website. On Wednesday July 21st we then hear from Blue Cross Blue Shield on Vermont on their rate request in the Qualified Health Plans and that meeting starts at 8 a.m. again taking place on Teams. And then on Thursday July 22nd we have a tentative rate review hearing fold if we need extra time. Then that evening Thursday July 22nd 2021 we have the rate review public comment form that starts at 4 p.m. and goes until 6 p.m. or until it's finished. That again is taking place on Teams and all of the information is on our website and on our press release for July. If you have any questions please reach out to either me or Abigail Conley. I also want to review a few special public comment sessions. I'll start with some ongoing public comment sessions related to the Qualified Health Plans beginning on May 10th and through July 22nd at 11.59 p.m. The board is accepting public comment on the proposed Blue Cross Blue Shield of Vermont and MVP Health Care Individual and Small Group Rate filings for Planned Year 2022 and you can make your public comment at GMCboardatvermont.gov or by clicking a form on our website under our special public comment period page. We also have a new public comment period that I want to announce and that is I'm looking for it I think I'm on the wrong page. Bear with me it is related to our rule. So I know it is up there it's just didn't refresh on my page. So the board is accepting public comment today June 30th 2021 through August 10th 2021 on the following proposed rule for rules for data submission and data release to replace the current rule that governs data submission and data release for Vermont's All-Payer Claims Database ABCD which is V-Cures. A public hearing is also scheduled for August 2nd 2021 at 2 p.m. The details on that hearing can be found on the Green Mountain Care Board's calendar of events and there's a link on our public comment web page and also information on these rules are located on our web page. So please check that out members of the public. Last but certainly not least we have an ongoing public comment period regarding the potential next agreement with CMMI for a next All-Payer Model Agreement. That public comment period is ongoing. We have shared and will continue to share those public comments with our colleagues at the agency of human services as well as the executive branch as they are taking the lead in the negotiations. And that is all I have to report out today. Thank you Susan. The next item on the agenda are the minutes of Wednesday June 23rd. Is there a motion. So moved. Second. It's been moved by member Holmes and seconded by member Pellum to approve the minutes of Wednesday June 23rd 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. Those opposed signify by saying nay. Let the record show as unanimous vote on the minutes. So at this time I'm going to turn the meeting over for the next item on the agenda which is the 2020 annual scale report to Michelle DeGree and Sarah Lindberg. So Michelle and Sarah whenever you're ready take it away. Thank you. I am going to share my screen. Can you all see that. We can. Okay. Excellent. So as chair Malin did Sarah and I are here today to talk to you about the 2020 or performance year three scale targets and alignment report. So again 2020 a year that has already passed but this is you know six months after is when we submit the report. So we will talk a little bit about preliminary 2021 data but I just want to reinforce that we're talking about last year in the purposes of this presentation. So the results for performance years one through three in performance year three there were 5 scale target ACO initiatives operating through contracts between payers and one care Vermont. Those include the Medicare ACO initiative the Medicaid next-gen program Blue Cross Blue Shield commercial next-gen program the Blue Cross Blue Shield primary program and the MVP qualified health plan program. So in performance year 3 as you can see from this slide Vermont achieved 47% Medicare scale performance and 45% all-payer scale performance with that you know we did not achieve Medicare and all-payer scale targets for performance year 3 preliminary data that we saw in performance year 2 kind of already anticipated this result just like we can see from our preliminary 2021 data sort of where we're headed for that performance year as well the performance year we're in now which is performance year 4. The APM agreement anticipate scale will increase over the life of the agreement and Vermont has previously described challenges to achieving scale in prior scale target reports in the and in the state's response to CMMI's warning notice following last year's scale target report. Some of this has to do with engaging hard to reach payers and how scale is actually measured. I'm losing my voice. I feel like Secretary Smith the other day now I'm losing my voice. I don't know what's happening so the APM signatories will continue to work with the ACO and other partners to increase scale the board through its ACO oversight and monitoring and other regulatory authorities and the governor's administration and agency on human services through strategies outlined in the APM implementation improvement plan which you'll hear from Secretary Smith and Ina Bacchus a little bit later today. The GMCB of course will continue to monitor new payer programs as they're developed ensuring services remain in alignment and qualify as scale target initiatives through the ACO budget process. Here's just another sort of quick way to look at this. I think one of the things that can sometimes get lost is really the trajectory at which Medicare and all payer scale targets grow. And so here's just another view that shows our progress in relation to the target. So we can see that Medicare trajectory and relatively flat performance more clearly I think in this graph then in the table version and of course preliminary 2021 data show us really closing that all payer gap. A quick look at attribution. So performance year three results reflect significant growth in attributed lives in both the Medicaid and commercial programs. Most notably the number of Medicaid bennies attributed under Vermont Medicaid next-gen program which launched in 2017. If you do the math it's increased nearly 300% since its inception and 45% growth over performance year 2. Similarly the commercial participation more than doubled from performance year 2 over performance year 2 and the additional increase shown there is due in part in large part for Medicaid expanded attribution model in the Medicaid space and in the commercial space through 2021 is due in part to the addition of the state employees in 2021 and Blue Cross opening up the primary program to a larger book of business. The Medicare growth that you see for preliminary 2021 projections is largely attributed to the Rutland Regional Medical Center joining the ACO program. I will talk briefly about factors influencing scale targets so there are several factors which contribute to achieving scale. Alignment to a scale target ACO initiative is contingent on provider participation specifically primary care providers participating in the ACO network. The payers engaging in agreements with the ACO and the methodology used for attribution. So as discussed previously success of the provider network are shown through increased participation in the Medicaid model and the comprehensive payment reform program continue to grow in performance year 3. Also in performance year 3 the provider network saw increased participation in both Medicaid and commercial space with the addition of the MVP as well as independent providers joining the network. In terms of payer participation there are quite a few challenges you know including that Vermont's preempted by federal law from influencing self-funded employer groups choices regarding their health insurance. So with Medicaid and with Medicaid's expanded attribution they've reached near saturation. They're at about 92% of attributable lives in 2020 with their expanded attribution model. And attribution methodology. So challenges to attribution include ACO attribution being provider driven and that there can be a disconnect where people live and where they receive care. You hear us talk about that a lot. The GMCB and CMS will continue to discuss these challenges as they pertain to the Medicare program since initial analyses suggest that achieving scale for Medicare specifically may be near impossible due to this attribution design. With that I'm going to turn it over to Sarah Lindberg to talk to you about some alternative measures that we have introduced in this year's report. Good morning. My name is Sarah Lindberg. I am a data person for the Green Mountain Care Board. Apologies I don't recall my exact title director of something related to data. If you could go to slide 8 please Michelle. So scale is a very complicated thing I think it's one of those things that the measurement challenges might not be as obvious when you're thinking about it but we thought that putting more context around how this model is really influencing the state of Vermont and its delivery system would be helpful and especially as we're thinking about how to evolve in the future. And so there were three different ways that we chose to look at scale by tweaking the way that it's specified in the model. So the first is we called adjusted scale and all that that one really does is give us credit where we think it's due in the denominator which means that we think it's not really fair to hold us accountable for the Medicare Advantage business since that's already a federally managed capitated arrangement. So without real investment from the federal side of things it's very difficult for us to have much sway on that population and it's getting more and more challenging as our more and more Medicare beneficiaries are opting for Medicare Advantage plans. The other thing that we think is pretty unfair is that we are accountable for self-funded groups even if we have none of their data. So due to infamous decision by the U.S. Supreme Court the GOBE decision self-funded groups often don't have to submit data to us anymore and so it's hard to reach out to people you don't know about or only theoretically know about. So this first measure just says let's let's be fair to ourselves and figure out what scale would look like under the terms of the model if we take those groups out of the denominator. The other two measures kind of flip it from looking at Vermont residents and instead looking kind of at the provider side of this model. The first of these is we called the proportion of Vermont hospital revenue and basically that says you know of all the revenue that's coming to hospitals on behalf of Vermont residents how much of it has really changed as a result of the all-parent model. So how many of these risk-based value incentivized payments are flowing through the system. And that I think is a better measure of how well the APM is helping to penetrate the payment delivery system at Vermont's hospitals. And the last measure is kind of looking at theoretically how many providers could even attribute to this model. So we looked at our best estimate of licensed and active providers in the primary care setting statewide and looked at how many of those are already participating in the ACO network. So if you could go to slide 9 please we'll start by looking at that adjusted scale. So this is showing the recalculated results from the first performance official performance year in 2018 through our preliminary estimate for the current year 2021. So we still need some numbers to finish our calculations for the current year but you'll see you that we start with an estimated all-parent scale denominator back out those Medicare Advantage beneficiaries back out the self-funded lives we're estimating that are not in vCures and then we reach this adjusted denominator and then we see what scale would look like based on that. And so we're still short of the target each year but much closer with our projections showing that we likely would meet the target in 2021. I think this also demonstrates why commercial participation is still very critical in making sure that this model penetrates all the full Vermont population. So that's really what's made the difference in performance years 3 and 4. And then slide 10 is that proportion of the hospital revenue. So what we said is okay let's look at any prospective payment a hospital is getting from the ACO as well as other reform payments. So those would be those associated with primary care medical homes community health teams and the other types of programs like that and compare that with those payments in addition to the net patient revenue the hospital receives. But to be fair in this calculation what we really need to do is estimate how much of that revenue is coming from Vermont residents. This model is largely constrained to Vermont residents based on attribution and so you need to make sure that you're adjusting for that before you can properly calculate this proportion. And so then you'll see back in the pilot year that Medicaid did we had about 1.9 percent of value-based payments. And this current I'm sorry this previous year that we've just closed in 2020 was up to just under 16 percent. So I think that probably lags behind our hopes but is certainly promising that it continues to increase. I also want to make clear that these fixed payments are or I should say prospective payments are flowing from one care to the hospitals. There is not a fixed prospective payment as part of the all-payer model flowing directly from a payer to a hospital. And so I think that we've maybe garbled some of that in our previous conversations and presentations. So the payment arrangements under the ACO are under the purview of the ACO. And so those are reconciled and managed within that network. The actual fixed payment happens from the payer to the ACO. And finally slide 11 I think is is one of the most compelling in my book and that's showing that you know 90 percent of primary care providers in the state are already participating in the ACO. So that that's a pretty good pretty impressive number and that's kind of showing you that you know they may not be participating in all three programs but they they are showing an investment and I think that's a testament to how important having this be a provider led initiative is to getting buy-in. So slide 12 I guess we'll just skip right ahead to slide 13 that's fine. So then we can talk a little bit about the Medicare target in particular. So Medicare scale is a bit of an enigma. It is a algorithm that is run by the federal government and despite both the best efforts here in the state of Vermont and also on behalf of our federal contractors who are doing the analytics for CMS no one's having much luck replicating the algorithm and unfortunately the system that provides performs the attribution for Medicare is kind of a legacy mainframe system. So we can't kind of just pull out the code and see what it's doing to try and improve our methods. So that's made it a little bit challenging to detect what might be going on or to kind of figure out how to analyze some of these target shortfalls. It's also a very important thing to flag in future agreements so that we can actually model this and address it on our side of the equation. But just not all Medicare beneficiaries in Vermont are eligible to be attributed to the all pair model through Medicare and there might be different reasons for that they for instance they are supposed to live in the United States for the full year. They're supposed to have both part A and part B coverage and they're not supposed to sign up for Medicare Advantage if they do that they kind of are wiped out from the Medicare attribution process. And so once you make those just eligibility based adjustments you know we lose quite a few beneficiaries. So we did this analysis in performance years 19 and 20 and we had about 93,000 eligible beneficiaries which is a drop of 20,000 folks. So if we look at that denominator our scale performance does improve we're about 20 percentage points below the target instead of 30 percentage points. So still shows some room to grow. But the other adjustment that is not accounted for here and is again a challenge with our limitations in understanding how attribution is performed programmatically is that some of the Medicare beneficiaries actually have primary care relationships outside of the state of Vermont. So that usually is either in New Hampshire and we actually have quite a few people who have primary care relationship in Florida based on the model due to our snowbirds. And so we think that even that adjustment would probably improve a little bit more but it's a hard thing to unfortunately model effectively and again is something that we are tracking in future developments as we think about new models. And I guess I'll turn it back over to Michelle to wrap this up. Thanks Sarah. Yeah. So just a few you know highlights you know the performance three performance year three results do show progress but ultimately we did fall short of the target. Again this has been known and clear to us since our performance year two report was released. The APM implementation improvement plan was created in 2020 to address issues with scale participation with the expectation that scale would increase in 2021 and beyond as a result of those efforts in our preliminary 2021 data are showing just that. And just an overview that the alternate measures of scale are provided to offer a fuller picture of statewide scope. Again penetration at the provider level is high and that FPP is continuing to grow as the model expands. And that's all we have for you so I'll turn it back to you Chairman Mullen for questions. Thank you Michelle. Thank you Sarah. Members of the board do you have any questions for Michelle or Sarah or any comments. This is Robin. Thank you Michelle and Sarah for a very thorough report and I really appreciate your additional analytics and thinking around the alternative measures of scale because I think as Michelle just said it was clear as a performance year two that the Medicare scale targets were really just off base quite frankly and while that was not at all known at the time of the negotiation I think now that we know it having these other measures to judge progress is really important and a good way for us to understand how the model is really changing over time. So I appreciate that a lot. Also I think that there is there has been some great progress and that is shown in the all-payer model target in terms of particularly the work that AHS has done around bringing in state employees and thinking about how to move forward in the self-funded. So that is I think interesting and I'm glad to see that included as well. So those are my comments and thank you very much. Thank you Robin. Are there other members of the board. Yeah I'd like to comment. I you know I when I first came on the board I took a look at these targets and the one that I was most comfortable with and familiar with was the two and a half percent per member per month growth rate and I could actually go back and figure out where that came from. It was Jeff Carr and Tom Gewett's work profiling the growth in the Vermont growth growth state product from 2001 to 2016 that 15 year period. And it's you know the three and a half percent is within a tenth of a point of that. But the scale targets these targets are for me much more difficult and I worry and I think we're getting to the point of correcting but I worry that we the process of establishing these targets was too aggressive maybe too much negotiated and not based on any kind of statistical you know study and if such exists I'd like to see it. But I just I just worry that that we we give these the 70 percent target and the 90 percent target this sacred standing of which we kind of beat our head against when if one goes back and look looks at it from the beginning the fair conclusion might be it was too ambitious not well documented and the kinds of changes that Sarah and and Michelle described are are reasonable and should be taken very seriously. Thank you Tom. Other questions or comments from the board. Hearing none I'll open it up for public comment or questions. Is there any member of the public who wishes to comment at this time. Hearing none I wish to thank both Michelle and Sarah again and that this report is being sent to Washington and they will have that today. And again thank you to the staff for everyone who contributed to that work and with that we will move on to the next item on the agenda. So next I'd like to welcome Secretary Smith and Director Bacchus to the meeting. And Mike and Nina are going to give us an update from AHS and it's always a pleasure to have you at our meeting. So Secretary Smith Director Bacchus I'm not sure who's going to lead off but whenever you're ready take it away. Well what's really dangerous Mr. Chair is Ian's going to let me lead off which is always dangerous and she can clean up anything that I say afterwards. So I do want to thank you. I do want to thank you pointing out on the scale targets some of the some of the issues that are associated with the scale targets meaning that when we negotiated the agreement and it's nobody's fault and nobody had done this before in the country that we when we negotiated the agreement we threw everything into the denominator in terms of attributed lives and in the numerator we could only use a percentage of that denominator in terms of attributing really attributing lives and you're going to have a gap. It's just going to happen as you move forward. So I do appreciate you know we're going to be obviously looking at in any sort of renewal of how you how you change that and I really appreciate some of the suggestions today particularly you know the participants and providers 90 percent for example that's pretty impressive but I really do do appreciate the work that's been done here and it's not surprising when you do that when you limit the what you can put in the numerator and you throw everything in the denominator you're going to have this gap as as you move forward. We are moving you know 2021 looks encouraging as we move forward and and one of the things that you talked about that makes it look encouraging are coming some of the things that we did and some of the things that we talked about in the improvement plan some of the things that you're looking at as well for example state employee health plan participation that was 12,675 individuals that come into the into the scaled targets Rutland Regional on the Medicare beneficiary side 7500 you know those help in a smaller state those kind of attributions help as we move forward but there's other things that we are doing as well. We're looking at you know one of the things that some of the providers were saying well we need more guidance on how we sort of can align our prospective payments and with Medicare remember that you have to sort of reconcile and they needed more guidance on that and we're helping them with the guidance on that in order to move more effectively and efficiently through the system you know you're you're looking at the ACO scaled strategy and keeping tabs on how the ACO is looking at scaled strategy. We are starting to engage self-funded groups. We're starting to engage payer engagement. As you know we put we provided a lot of money in stabilization grants to shore up the health care system during the pandemic but one of the things that I want to spend some time on that we're looking at is that this this movement and I've really become a champion of this this movement to true fixed payments in all all our systems whether it's commercial Medicaid as you know we're pretty we're pretty advanced in Medicaid in terms of fixed payments but also in Medicare as we move forward and that's one of the things that I want to talk about that we are particularly looking at as we negotiate another agreement and we're we're still trying to determine whether it's a year extension whether it's more than a year there seemingly is mutual interest in moving Medicare to a value-based payment system and if we can achieve that we can bring in the commercials we can continue doing what we're doing in medic Medicaid we're at a value-based payment and let me tell you why that's important I saw that value-based payment happened during the pandemic when prospective payments short up everything it it provided cash flow it provided everything because we had shut down the system for elective surgeries and so there was no money coming in the prospective payments allowed cash flows cash flow cash flow to happen but I want to be clear I'm committed to moving away from fee for service reimbursement for this reason I think is perverse I think it rewards all the wrong things as we move forward you know it today sort of the healthcare system operates to make money on each additional and more costly procedure even if the person isn't better off and instead of this payment model I want to move to a different maybe model that gives you a fixed fee payment that gives you a prospective payment or a value-based there's a lot of words that all mean the same in that we need to give the system a predictable budget and up from money so that they can focus on keeping Vermonters healthy instead of ringing up a tab and and the highest level at the highest level this is called a value-based payment and that means across all payers it means Medicaid Medicare commercial insurance I think we have a window of an opportunity here with Medicare as we start talking about the all-payer negotiations now the all-payer there's different things going on here a lot of things going on there is the global commitment waiver which ends at this year there is the all-payer model waiver that in they're all 1115 but that that ends in 22 but we're negotiating they're connected and we're negotiating with the eye on both as we're as we're moving through these various models so the idea here is to really focus on the major types of health coverage and make sure that they pay in the same way they commit to improving population health and then providers have a consistent incentive across the board and a reduction in administrative cost and that's what we're trying to do here as we look at the all-payer model as we connect it to the global commitment model and we've seen some success in Medicaid for example you know when we look at the Medicaid budget it's going on an average of 1.45 percent compared to an average of 5.23 percent in the five years preceding sort of the model we also highlight how important it is for Medicare to move even closer to Medicaid in how it pays you know as we talk to the federal government so the improvement plan you know we talked about the scale but you know what and we talked about various alternatives that we certainly will take into the negotiations and talk about but what I want to leave you with is I'm really committed to this value-based payment at the highest level we'll call it value-based payment I'm really committed to this value-based payment payment or fixed fee and I'm committed to moving as quickly as possible if there's an opportunity I'm going to take advantage of it to move as quickly as possible and right now the federal government is saying to us there may be an opportunity so I am looking at that I just wanted to give you an update of where we are in the the negotiations and and for one meeting in the last two days I haven't lost my voice which is amazing so with that I'll take questions from the board Mr. Chair. Super thank you very much Mr. Secretary questions from the board or comments Tom. Me. Oh I thought you lit up in blue. Happy to jump in if you aren't ready Tom. Well I'll just bring up one one topic gently that concerns me and that is the cost shift you know going into this last legislative session the presentation to the emergency board clearly stated from diva that there would be no rate increases Medicaid rate increases in 2021 but for any that are federally required and that had mostly to do with FQHCs and and so I just worry that and clearly the cost shift is not fixable I mean that's something we're going to have to live with forever it's such a big number you know our calculation is that it's for 2020 it was like something like 240 million dollars 250 million dollars and I did take a look at the data that CMS has required Vermont all hospitals across the nation to present and if you look at the 70 shoppable procedure codes the Medicaid payment in Vermont from to UVMMC in comparison to the Blue Cross Blue Shield payment rate is 42 percent so the cost shift exists and it's a it's a big force and I worry that that what I hope I'll talk about hope I hope that we can find a path forward with Medicaid that very slowly and incrementally increases that the either the payment rate or the fixed prospective rate that is based on the payment rate so that it doesn't act as kind of a siphon I worry that that the all pair model might be successful that that is we move up the number for fixed prospective payments to something where we're at a purely at a good leveraging point for the innovations that people say can be delivered but that that gets kind of sucked away in terms of one of the major players being Medicaid you know just kind of standing still and so you know if some kind of program like you know a commitment to a 2 percent money increase especially in an environment where the Vermont population is aging you know and and migrating from Medicaid to Medicare so and that 2 percent is 1 percent new money and 1 percent efficiencies I don't know but trying to find some way that providers out there have some assurance that that the cost shift isn't maybe going to be fixed but that it's not going to get any worse and so that can be part of the of the understanding that we have as a community that will do the best we can to get the Medicaid payment rates up it's just just my my concern noted commissioner I was just going to say that a finance commissioner never changes his stripes you could at least have said duly noted okay Robin yes thank you secretary Smith for joining us today and laying out your vision and commitment I really appreciate that I share your commitment to value-based payment and would love to see us as a state move towards greater fixed payments particularly or true fixed payments as part of a value-based system particularly for the hospital sector and I think there has been some good success in one care is comprehensive primary care pilot for primary care as well so I'm hopeful that we as a state can further develop that vision moving forward into the next federal agreement related to Medicare I also just as a practical matter I think that the idea of a one-year or fairly short-term extension makes sense just given everything that it faced the state related to the pandemic I feel like we've really lost a year year and a half maybe a full two by the time we get through all this in the all-pair model which just from a data perspective makes it challenging as well as I think from a delivery system transformation when providers needed to really focus on transforming for the pandemic you know that took away bandwidth from transforming around the payment reform that we've been working towards so I think that's a great idea and I think it would help us then move forward and give us time as a state to fully develop what a what the next version is moving forward so I just wanted to to share those thoughts with you in the public and also just say thanks for your leadership around the self-insured employers and the state employees I think that's a role that really the isn't particularly amenable to a regulatory body participating in so we really needed that leadership from you and I appreciate it so those are my thoughts well thank you for the thoughts one of the things I just wanted to I mean we're looking at a year extension but if there's an opportunity to bring Medicare into the value-based payment and the the the offset of that is to go a little bit longer I just want to I just you know in negotiations I may take advantage of it sure sure I mean that makes it makes sense and I think you know a lot of the there's a lot of flexibility quite frankly in the current agreement around moving the Medicare payment that quite frankly just there hasn't been the bandwidth to pursue given the pandemic and those sorts of things so it seems to me like those are not mutually exclusive and it makes sense to see how it goes it's always having been in some of these federal negotiations you do have to be a little flexible thank you Robin other members of the board sure I will jump in here just want to thank you Secretary Smith for coming today as always your leadership on the pandemic and your leadership with taking you know some charge of these negotiations with the federal government I too completely agree with you and that we need to move away from deeper service and fully support true fixed payments by all three payers or all three types of payers appreciate the need to maybe extend the agreement for a year but also appreciate if they can you know hasten the movement of getting Medicare into true fixed payment without reconciliation seems to be the way to go that seems to be a major obstacle to participation and true delivery reform I'm wondering if you have thoughts around what the greatest obstacles might be to getting the commercial market to true fixed payment I mean I think you know Medicaid has done a fantastic job Medicare will involve some negotiations how do we get the commercial side of the market into true fixed payment that's really a great question and I don't have an answer to that right now because I haven't really started to engage the commercial market as you noted I've been a little busy on something else so I haven't really had the opportunity to engage them that's on my plate to start engaging to find out what are some of the obstacles to that and what are some of the opportunities as well I mean my first my first thought was let's push forward with Medicare and we have Medicaid and Medicare we're sort of homegrown with the commercials in a way maybe we can have as as equal success with them if we have Medicare and Medicaid sort of aligned as well so I I can't answer your question right now because I don't know the answer to it but it's a question I'm going to ask in the next 30 to 60 days fair enough thank you okay other comments or questions from the board sure first thank you very much for the presentation and you know I think adding to you know along with trying to get the commercial side you know how do we how do we get beyond the hospitals and the private practice and other areas as well so I think to you know to truly be able to get into that you know fixed payment across the whole system so so any help you can get there there as well would be helpful but this presentation was great thank you yeah it doesn't it doesn't work properly and unless we can get all three participants into this into the value based or fixed payment system and and that's my goal here great thank you anything else from the board if not at this time I'm going to open it up for a public comment does any member of the public wish you comment at this time and I'm going to question Kevin I've got a question Kevin is that ham yes sir okay ham davis um thank you um on this one of the things that's happening is that the you get we're having a conversation here that's highly technical policy analysts and people that are totally can totally on the end of this the thing that strikes me is a huge problem is that um what's what seems to be going on as far as the public is what and what the public can actually see is that the that the auditor Doug Hoffer okay is running an obvious attack on the whole system and is trying to build a case but not not going in for another five-year thing in another five-year term in the in the uh in december uh so my question my first question is this um one of the problems is that that hofer uses a lot of numbers but our guys our side never uses numbers okay and so my question is if we have we have huge capability between the green mount keyboard and ahs in the both the financial and the policy side and so my question is we started with the reform in the reform in uh from 2013 when it really started until now okay needs to my my figures show that from 2013 to 2019 we have vermont has avoided 1.9 billion dollars okay in in spending that they didn't have to pay so what i'm asking what i want to know is is if somebody in either the grand mountain keyboard or ahs who can have any number at all what have we got so far have we saved any money if you can't answer that question you're going to get nowhere with the public and nowhere with the legislature well here's what i can do ham um and it depends on where you start and where you end when you look at figures if you think for example the health consumption expenditures in compare vermont to um the us in total um you know every year we were over the us average except 2007 up until uh 2010 from 2011 uh i believe from 2011 on we've been under the national uh average and if you look at um the first performance year of the model which was in essence was 2018 for expenditure reasons you can see that the national average of health care growth in health consumption expenditures was 4.7 percent and we were 1.9 percent now this bounces around um but it does display sort of what i think you're talking about and and if you say like from 2000 to now that expenditures grew x amount yeah they did um memory they grew quite heavily from 2000 to uh uh 2010 um but they have moderated in this year compared to the national average and and i think you got to use some of the statistics um in comparison to other places about how we're doing um and and that's that's how i look at it i don't know if that answers your question well it it it well in it it talks about it's in the same area what you need to do is to convert it to money my i'd be i have the figures the i have i have the figures on 2000 to 2009 in 2010 there was a huge drop because of the 2008 recession and and uh l i uh surgery a lot of surgery procedure disappeared in 2011 and 2012 the cap was not set by any regulatory body it was established by the legislature in act 48 okay so the comparison needs to be what is 2000 to not 2009 compared to 2013 to 2019 the model didn't start in 18 the model started in 13 because the model involves both regulation and then trying to change from away from fee for service but the model the reform effort the vermont reform effort runs from 2013 to 2019 and nobody has put a single figure take the figures you just described what does that you're not going to be able to talk to hoffer unless you get a number he's saying that what we spent what we what we've done is lose a ton of money now what the public is going to hear and what the legislature's going to hear is vermont reform has cost vermont is a lot of money they've lost a lot of money okay if nobody can say anything about that then you're going to get nowhere because you cannot do this kind of reform unless you can take the public and the legislature with you that's a comment i understand thank you so i appreciate that ham and if i could just jump into that dialogue in in this in no way is disrespectful to the state auditor because i appreciate the work that he's doing but ham the true gold standard for a measurement of the all pair model is that evaluation which is being conducted by the University of Chicago norc and that norc evaluation although the auditor is correct that a full evaluation of the model won't be out for years we know that there will be a preliminary investigation of the initial couple years that evaluation will be out later this year and so that's a true independent evaluation it's it's not being you know led by anybody that's trying to justify the existence of the all pair model and i think that you're going to have that evaluation for at least the first couple of years ham later this year and i think that will be a major help to everyone as we move forward well i i just disagree with that kevin and i respect your view the report it seems to me that you got to have a number and the what the both the both of the scott administration and the green mate mountain care board is paid to do is to get what's to work to get this system to work to help her monitors and and the fact is the numbers of the and norc or smork the reality the numbers exist we've got them all whether they they want the people in chicago i'm not going to have a single number that we don't have and and so what you have is an aggressive player in hoffer you may respect him but i don't the the you get an aggressive player who's manipulating the numbers to show how bad it is okay so you don't have to even talk about you don't have to mention hoffer what you need to do is get the you've got the numbers and you want to tell people what those numbers are never mind what norc thanks excuse me thank you i'm done thank you ham mess message received um next i'm going to call on eric strong eric i see a hand up from eric strong are you are you there yeah uh it should be julie washerman i'm not exactly sure why it says eric strong but it's julie washerman uh and i have a question um so it's for um secretary smith um the uh agency of human services has just submitted its application for the global commitment medicaid waiver renewal um in that application uh a hs is planning to have diva become a public state run risk bearing medicaid managed care organization um a hs will pay diva a monthly capitation rate through each medicaid enrollee so um if diva is running medicaid bearing the risk of capitated payments uh addressing population health which is also part of the application and reinvesting its savings into medicaid programs um it appears to some that uh this is um what the aco has done but um if the state's going to do it then it um seems that the aco is is uh being duplicative uh having the aco would be duplicate duplicative so my question for you secretary smith is what role will the aco play with uh starting january 1 with the renewal of the global commitment um having the state be a risk bearing medicaid managed care organization that bears risk and reinvest its savings so thank you for the question let me just um sort of frame up this question in 2005 there was a uh secretary of human services that would came up with this strange idea that just give us the money let us pay for let us use it the way that we want to and any of the savings that we have will reinvest into the medicaid program it was called global commitment and it was a 1115 waiver um and um i wish i could take all the credit for it but there were a lot of people that were working on that uh that waiver it was a unique concept where we set up an mco which was uh over at the time a managed care organization and use that mechanism which was never done before never uh accomplished before use that mechanism in order to um to use medicaid in a much different way it gave us so much flexibility and how to use medicaid maybe too much flexibility and ultimately the federal government thought that too and started to rein in the flexibility uh that we had in in the medicaid model we've started we started losing some of the advantages that we had in uh in over the years as medicaid started to put rules on rules on rules um but we haven't really we've sort of changed our designation but we still pay a capita payment through ahs um to diva now and that hasn't really changed what i have said is let's go back to the mco model let's go under the rules now that they have under the nco model because they're mature enough we know what the playing field is let's move into that so nothing really changes in terms of of there'll be some might there'll be some organizational changes that we'll have to do within ahs but that how we use the aco which is sort of through using it as a funding mechanism to get out to providers i don't think it's going to change all that much um and i don't think it's going to be duplicative because it's basically what we're doing now just under a different model under different rules and gives us more flexibility i want to eliminate the investments we have we have caps now on caps and i don't understand how that happened but but we want to invest we want to eliminate those investment caps in the 1115 waiver and i know half the audience i'm i'm i'm losing but you know we have we have an overall budget neutrality cap that we've always had um and then now since 2016 we have investment caps in here i want to eliminate all that cap and just have one cap like we used to um and so i don't see um the the outward mechanisms changing i do see the inward mechanisms changing and and what rules we have to follow as we move forward i hope i answered your question um kind of i guess my concern is that when medic when the state is bearing the risk that's a very different model than when the aco is bearing the risk and when the state gets to reinvest its savings that's a very different model than the aco having the savings to do uh their you know their approach to reinvestment yeah but we we've had this experience for many many years in terms of 2005 to about 2016 and the the experience we've had from 2016 on is not that much difference just under a really um wonky funky model that the government put us in that nobody understands including the federal government right now okay thank you thank you jay is there other public comment is is there other public comment i see no hands raised and i'm not hearing from anyone so um thank you secretary smith thank you director back us it was a great conversation and uh it's always a pleasure to see you and to uh work with you we know that you're dedicated to uh making health care better in vermont and uh we look forward to uh marching with you on that mission thank you thank you very much so at this point we are going to um change gears and we're going to um move the conversation to a request for a waiver from um clover health partners llc and i'm going to turn the meeting over to russ mackrack and russ thank you mr chair i have a couple of slides i'm going to present here and so hopefully you can see my screen we can great thank you so i'm going to endeavor to frame the discussion of clover health's waiver request uh which clover health presented to the board last week um to that end there are three parts to this the short presentation uh the first is setting out clover's request in the context of the basic regulatory framework um the second is to make note of some reports concerning clover health which has been an area of public comment and lastly to uh hopefully help identify some specific decision points uh for the board with respect to this this request um a quick note the slides that were posted yesterday had a omission that's been fixed and the corrected slides were posted this morning and i'm uh using the corrected slides here uh so as an overview as clover testified last week is a direct contracting entity um they are treated as an aco and subject to the board's oversight under um statute 18 bsa 93 82 and the board's rule uh aco oversight rule 5.0 um clover health is a medicare only aco in vermont and it's not subject to the certification requirement that comes from the statute uh which says that to be eligible to receive payments from medicaid or commercial insurance through any payment reform program or initiative an aco needs to be certified as medicare only uh clover health uh is receiving neither medicaid nor commercial insurance through payment reform programs and so they are not required to be certified to operate in vermont this is relevant because the question before the board is not whether to allow clover health to operate in vermont or whether to certify clover but rather the question is under what conditions clover health operates in vermont and specifically it's whether clover health's budget is subject to review and approval and whether clover is subject to the reporting enforcement provisions of the of the rule um the aco oversight statute and the board rule uh under the aco oversight statute the board adopts rules to establish the standards and processes for reviewing modifying and approving aco budgets uh rule five implements that statute both the statute and the rule treat budget review for acos with fewer than 10 000 attributed lives differently than acos with 10 000 or more lives specifically in reviewing the budgets of acos with 10 000 or more lives the board must take into consideration the criteria listed in 93 82 b1 but for acos with less than 10 000 lives and this is the group that clover presently falls into the board reviews the budget taking into account only those statutory criteria that the board deems appropriate to the aco size and scope that comes from the the rule and I think the relevance of this will be clear and as we go through the decision points next I wanted to note that there have been public comments regarding reports of investigations and litigation that clover is facing uh chair melin brought this up last week in questions to clover health in light of the comments in the chair's questions it seems useful to run through what the those reports have been I have a slight caveat here that we're not in a position to draw conclusions about the accuracy of the reports the materiality of any investigations or merits of any litigation so this is to note that these reports and disclosure and responses exist uh on February 4th there was a wall street firm called hindenburg research it issued a report a lengthy report fairly lengthy report on clover health part of that report said that in october of 2020 the u.s attorney's office in philadelphia issued a civil investigative demand to a former clover clover employee uh hindenburg posted a copy of that demand letter with their report uh the demand letter says it's part of a false claims act investigation and a required clover's former employee to provide oral testimony uh on a dozen different topics um relating to patient recruitment uh patients for our payments for patient recruitment and generating leads referral payments uh and any activity intended to discourage providers uh to refuse to accept patients with non clover coverage um these questions appear to me related to clover's medicare advantage plans uh clover responded to the report on february 5th at length emphatically denying any violation of law or regulation and saying it has only received a request for information from the doj which it complied with uh clover generally said they're a heavily regulated entity uh as are other organizations that participate provide medicare advantage plans and they frequently receive requests for information from regulatory bodies clover also referred the board to this response during its presentation also on february 5th the sec commenced an investigation relating to aspects of clover health's business and allegations in the hindenburg reports that was disclosed in uh clover's public filings also disclosed in in clover's public filings its um directors and officers are defendants in securities class action lawsuits and a shareholder derbit lawsuit excuse me uh which were filed in february 2020 and clover describes them as generally based on the allegations in the hindenburg research piece um i took a quick scan of those complaints and i think that is an accurate characterization of them uh noted in 2016 cms imposed a monetary fine of $106,000 on clover for inaccurate statements that out of network providers were obligated to accept clover enrollees according to the letter clover failed to correct the misleading statements after repeated notifications from cms and separately i'll note because because it was subject of a article in new york daily news this month um there's a for-profit hospital group in new jersey called care point that is owned or was owned by clover ceo that hospital group was subject to news reports from a couple years ago regarding the high prices it charges including one analysis that characterized it one of those hospitals as the most expensive in the country and additionally an investigation by the state new jersey regarding payment of management fees by that hospital group uh was not clover it was um a hospital group owned by the the clover ceo so with the caveats noted the outset um were aware of these reports and allegations and also the clover has denied violations of law moving on to the waiver request specifically the standard for waiver uh comes out of the board's aco oversight rule in five six oh one and the board may waive applications of any provision of the rule upon such conditions the board requires in order to prevent unnecessary hardship or delay in order to prevent injustice or for other good cause uh and that's unless precluded by the rule itself or the statute and i don't believe in this case it either the rule of the statute would preclude a waiver uh clover requested waiver of board rule 5.4 and rule 5.5 so um what this um somewhat inartfully presents is a decision tree something resembling a decision tree for the board so with respect to the um request for a waiver of rule 5.4 the board has an initial uh what i think is an initial question of whether to grant the waiver or not grant the waiver uh if the board decides to grant the waiver there are a series of subsequent questions um that would be helpful for the board to consider um for what duration is the waiver as conditioned on the number of attributed lives and clover being a medicare only aco uh other conditions um and whether certain reporting would be required of clover i have listed a couple of examples here like a list of participating providers in vermont terms of provider contracts with vermont providers a shared savings loss plan information needed to determine if it's scale qualifying under the apm should also note the number of attributed lives in vermont um perhaps quality metrics or perhaps other information not identified in this slide alternatively if the board does not decides not to grant clover's request for a waiver it seems there are two possible courses following that that decision the first would be to adopt a position of monitoring um uh monitoring clover requiring certain reporting and doing that pending the board's development of budget guidance uh for an aco like clover that has fewer than 10 000 lives if the board did not want to go with the uh monitoring only position then the board could not grant a waiver and require budget review and approval given that the both the statute and the rule provide the board the flexibility to tailor the budget uh review and approval process for an aco with fewer than 10 000 lives that budget review could be done based on information clover submitted to date or could be information submitted to date plus any additional information requested by the board and as required as part of the budget review process there's some further question there as to which of the statutory criteria the board deems appropriate to clover based on its size and scope the second part of clover's request is for a waiver of the monitoring and enforcement rule um this one is a slight slightly different I think because you the board could consider a waiver of the of rule 5.5 no waiver of 5.5 or or partial waiver meaning the waiver of specific sections within 5.5 and I find it kind of helpful to think about 5.5 in terms of um aspects of the rule that require compliance with board orders and allow the board to discretionary allow the board to assert specific requests or make specific requests of clover and take specific remedial action on the one hand and on the other hand requirements that require clover's ongoing compliance without specific board direction those would be uh aspects like the record keeping requirement um which the board might find is already covered by clover's requirements as participating as a direct contracting entity and also some of the public reporting aspects of 5.502 that require clover to post certain information to its website the board could determine or adequately covered um already by the requirements that clover is subject to from CMS and so that I hope is a helpful framing of of this discussion and I will pause there. Thank you Russ. Do board members have questions for Russ? So this is Robin. I don't have specific questions this moment but I did think it might make sense for us to have a little bit of a discussion around where we are on the two questions and as part of that um if we have questions related that where we really need advice from our general council I do think that would be most appropriate in an executive session but I was thinking there's probably some more general discussion we might have before that but I don't know so I'm happy to kick that off but I just thought I'd throw that out there. Appreciate that Robin. Shall I kick it off? Yes go ahead. Okay so when I'm thinking about this question I think there are two different considerations that I'm weighing on the one hand this is a Medicare only small direct contracting ACO program that involves one Vermont practice and a limited number of Vermont lives and I do think that it that our regulatory process must appropriately reflect the scope of the Vermont business so um so that is one consideration I think it would be inappropriate to do the type of um budget review that we do for example for one care given that this is much smaller and includes one practice. Now with you know if Clover did attract more business as they indicated they were hoping to do that consideration changes over time but given sort of today's snapshot with one provider and no preferred providers and a small number of people that's kind of where we are today so that's one thing that I'm sort of thinking about when I'm thinking through this process. The other piece as Russ said is that you know they we don't have the authority to certify them so it's not a question as he said of whether they can operate or not operate it's a question of what kind of parameters and public reporting and transparency is appropriate um and then the the third consideration that is swirling around in my head is um that I this is for Vermont a new model there there are um you know I think we we got a little bit of a sense of the model of care that is embedded in the Clover Health app. I don't feel like I totally understand how that fits in with the statewide vision for payment delivery system reform in terms of care management and not having duplicative or redundant systems which we as a state as a small state try to not increase duplicative sort of efforts. So I think for me I am probably leaning towards one of the no waiver options and I don't know and that's where I would need to have further discussion with our general counsel to determine which path as Russ has outlined on the slide makes more sense. In terms of the monitoring and enforcement I'm not given the amount of information that I know and sort of the uncertainty about growth of Clover overtime. I'm not particularly comfortable with a complete waiver there. I would need to think a little bit more about the the the kind of middle ground which is where I think I probably would be more likely to land whereas if it's a reporting requirement that CMS has covered I don't you know and this is duplicative I'm sympathetic to not creating that duplication. On the other hand I wouldn't want to waive the enforcement ability. So so that's kind of where I'm at. I think you know I do think that there are some interesting aspects that they described about their model. For example the getting some getting a patient who's been discharged from the hospital in with their primary care provider very quickly or ensuring that there's some other appropriate touch point as long as that's connected back and the care is coordinated with the primary care provider that could be really good for Vermont patients. I think that's often a place where our system currently falls short and just speaking from personal experience I had a family member who had an injury and you know it it took basically me getting in getting in there to get the care coordinated and and organized and that still took a week. So that aspect some of those aspects of improving that communication and kind of speeding up that care process for Vermonters I think are interesting. Also you know there has been some discussion in the state about you know whether or not one ACO makes sense. I you know I tend to fall in the camp of we're a small state. We don't want to have a lot of redundant administrative processes but at the same time you know healthcare in most of the country is a marketplace and so we're not completely immune from that regardless of what my personal opinion is. So sorry if that was a bit rambling but I'm just sort of thinking out loud to share kind of where I am. So it wasn't rambling and I appreciate it very much Robin. I too have come to a similar place although I'm not sure that we're in the exact same place at this point in time but for a number of reasons I don't believe that we should just be granting the waiver and with that being said I think there are some difficulties that we have to address as far as the fact that this is a calendar year entity that started in April of this year in Vermont so we don't get a real full year from their first year and that's going to create some difficulties. I think it would be very difficult for staff to put together a reporting process rapidly so I don't think that 21 truly is an option for reporting but I do think that there has to be some common ground here and I mentioned it at last week's meeting when I asked the vice president of Clover if there couldn't be a way to align the reporting and basically that I'm not looking to duplicate anything that CMS is already requiring from them but I am looking to make sure that Vermont and Vermonters are held hold and by that we didn't really hear a concrete way in which the savings were going to be in a meaningful way to offset the $45 fee that they're paying just to have someone open up the program and there were more I thought more questions raised than answers received at last week's meeting and that makes it very difficult to come to a conclusion but one thing is for certain that we likely share their goals on the care coordination and this is something that has been integral to Vermont's health care reform efforts dating well before the all-payer model it goes back to blueprint for health and even prior to that with the community teams and that's something that could be very beneficial to Vermont but at this point there's no guarantees that whatever is siphoned out of Vermont is going to be beneficial in my mind until we actually get a report of some results and so for that reason I'm kind of leaning on the no waiver as well in a modified way and that's where I'm coming from other members of the board sure I'll jump in too you know I think you've both you know put it put out good good scenarios and I'm looking at you know also a modified waiver here I mean I think we're not going to go with a waiver I guess is my answer it would be but but a modified waiver and I'm not as concerned I think this is going to evolve over time so yes you know they may be on a different calendar and we it may take us time to get what types of reporting that we need so I think the first decision is really are we waiver or no waiver right and and and then once we get beyond that and it's it seems like we have three on the no waiver so we'd have to see you know where the other two are you know then it becomes what what what will we do and I don't want to be overly restrictive on them as to what we're requesting you know certainly it's it's they're small right now they may grow to be bigger they may get over the 10 000 and at that point you know there may be additional needs that we have but you know I would like to work with the data that we have you know and so maybe a waiver with the budget review based on the information that we have we'll be able to ask questions and you know and kind of continue down that process they're already here they're they're already in the state you know they're allowed to be doing that it's just a matter then of what requirements we put on them and whether they adhere to those or not and if and what enforcement would be if if they don't so you know I'm certainly in the no waiver but um you know in a varied modified version on what we'll request what information we'll request and working with our staff on what that would be thank you more any others well I think that we seem to all be coming to a consensus here um at least that there probably isn't going to be a straight up waiver some kind of partial waiver modified waivers where I'm at as well you know again we don't have the authority to determine whether they can operate in the state or not they're here they're operating the question is what kind of monitoring what kind of budget review what kind of actions we can take within our statutory authority I feel like I need more information as chair mullen said I feel like more questions were raised last week than answers I do however think that the regulation should also reflect the scope and as Robin said you know right now it's limited to one practice in very few lives but they did talk last week about growing quite substantially so I think our our oversight will have to you know pivot with that and grow with that potentially I see some you know this potentially could be an innovative model this could be great for monitors if there's more data on cost and quality then then providers have had access to before at their fingertips at the point of service I think that's great there's enhanced funding for primary care providers which we know primary care providers need so that's that's helpful so I you know there's there's I see pros and cons I you know I'd like to hear from our general counsel on some of the legal issues I think an executive session would be helpful you know my sense is I need more information I'm not comfortable with a full waiver I'm comfortable with a modified waiver possibly some review with the information that we have not trying to increase administrative burden but making sure that you know that we're doing right by the monitors here thank you Jess Tom so I think I'm in the pack here um the uh you know my concern is is in part timing I mean we're in the middle of negotiating an extension on the all-payer model and uh and and possibly renewal and I'm you know I'm I'm I'm concerned if I don't understand um that you know here is CMS possibly injecting another player or supporting another player into the Vermont scene and I don't I don't know whether they compete with each other or they're compatible so there's some kind of market issues there that I just want to know more about um I I do think that a waiver of a short period of time will help some of these securities and exchange issues kind of play out a little bit more um because they're unresolved they're just allegations at this point by and large but but you know not fully resolved and I'd like to find out more from CMS what we can have of their file um I did ask the question you know uh you know they clearly said that in their presentation to CMS CMS Vermont data would be bundled with the entire uh you know operation and so the Vermont data wouldn't be just you know distinguishable and I don't know whether or not that's true or not but I I'd like for us to have a conversation with CMS to figure out uh um what is the maximum amount of transparency we can have about uh an operation in Vermont that is serving upwards of 5,000 people which is 5,000 Vermonters that we have to be concerned about so if if we're going to rely on on CMS's data you know I want to have a solid sense of what it is that we can have on a routine basis not filing a Freedom of Information Act but on a routine basis for a near term waiver possibly um and uh and take that into consideration I know that uh both uh Jess and Robin mentioned that they would like to hear from the legal team in executive session um is there anyone who wishes to make a motion concerning that at this time I can do that um so all right hold on just one second I'm pulling up my background material because these ones are a little bit complicated and not good to do off the top of your head um so the motion that I would like so there are two motions that I think we would need before going into executive session and so the first motion I would like to make is that we find that the premature general public knowledge of the legal advice of our council regarding Clover Health's waiver request would clearly place the board at a substantial disadvantage in any challenge that may arise out of our board out of our board decision so the the motion that is that we find that that is the case because we are required to make a specific finding a second but is there any discussion on the motion if not all those in favor of the motion signified by saying aye aye okay anyone oppose signified by saying nay let the record show it was unanimous vote and Robin you said you had a second motion yes uh now I would move that we go into executive session to consider a confidential attorney client communications regarding Clover Health's waiver request under the provisions of one vsa section 313 a1f um I'll second it okay I am looking at the clock and I just want to be able to give a time certain that the board will come back into public session so I am going to set that time at noon where we will come back into a public session and with that all those in favor of the motion please signify by saying aye aye those opposed signify by saying nay so thank you we will be recessed from the public session until 12 noon and board members I believe that you have been sent a link for a possible executive session from Abigail and if you could exit this meeting and go to that meeting it would be helpful and with that I just want to make it clear that it's not just the board members it's also the legal team and the appropriate policy staff we'll see everyone else at noon so welcome back to the Green Mountain Care Board and we just completed a discussion with our legal team about the legal options that were available to the board and with that we're about to continue discussions on a request for a waiver by Clover Health Partners LLC and with that I will open it up for for discussion. I'll jump in this is Robin thank you thank that was it was helpful to me to be able to get our legal advice from our attorneys and now that I feel like I'm clear on it on those issues I would actually be ready to move to make a motion but I don't want to be premature if other board members had items they wanted to discuss before I do that. Well they could still discuss those items even after you make a motion. All right then I'm just going to go for it. So I I move that the Green Mountain Care Board deny Clover Health's request for a waiver from the ACO budget process. Is there a second. Yeah I'll second that. Okay further discussion from the board. I think the only other I would just reiterate you know for me it is important to have some process it will be important to ensure that that process is tailored to the size and scope of a Medicare ACO program so I I just I I do think it should be clear and I think it will be clear I have a second motion I'll make if we approve this one that we certainly are not expecting that Clover would be submitting a budget under the existing ACO guidance that's out there given that that's tailored to a different process but I do think it's important to have transparency in our process and since we are trying to implement a statewide model to understand new market entrance in their role in that statewide model. So before we go to a vote I'm going to open it up for any public comment on this discussion about Clover Health Park partners request for a waiver under rule five. Is there any public comment seeing and hearing none. Is there any further board discussion hearing none the motion before us and again who seconded it. Maureen thank you just wanted to make sure that I had made sure there was a second second. Is that the Green Mountain Care Board deny Clover Health Partners LLC request for a waiver under rule five. All those in favor of the motion signify by saying aye. Those opposed signify by saying nay. Let the record show is the unanimous vote and I believe Robin I heard you say that you may have a second motion. Yes Mr. Chair. I would move that the board delegate to our legal and policy team the task of coming up with a budget process and reporting criteria that are appropriate to the size and scope of Clover Health Partners and that also that that process would include input both from Clover Health and from the Health Care Advocates Office. Second. It's been moved and seconded. Is there discussion from the board. I think it was probably clear from what I said before but I think that having our staff work with the stakeholders would be important so that we can make sure that the regulatory process is appropriately sized and I think that that will also be by delegating it to our staff it'll be a more expeditious process than trying to do it through our public board meeting process. Of course it would be necessary for that to come back to us once it's developed. Thank you Robin. Is there other board discussion. Before I open it up to public comment I just want to I see that Eric Schulteis is on this meeting and I just want to make sure that the Health Care Advocate is comfortable with helping to provide input in this process of developing what is the proper reporting. Hi Kevin. Of course we are. Thank you. And I'm not sure if I see anybody from Clover Health but I would assume it would be in their best interest to provide input so with that I'm going to open it up to public comment on the motion that's in front of us. And that motion is to delegate to the Green Mountain Care Board Legal and Policy Teams the responsibility for working with input from the Health Care Advocate and from Clover Health partners on what would be a proper and non-duplicative reporting. So with that members of the public and budget process and budget process yes members of the public again hearing none I'll send it back to the board is there any further discussion hearing none all those in favor of the motion please signify by saying aye aye those opposed signify by saying nay let the record show that this motion passionately as well. Thank you Russ it was very helpful discussion and we look forward to hearing back from you and the policy team about you know what the next step should be so good luck in your journey. Thank you. With that I'm going to move to old business is there any old business to come before the board at this time. Hearing none is there any new business to come before the board at this time. Hearing none is there a motion to adjourn. So moved. Second. It's been moved by member Yussefer and seconded by member Lunge to adjourn. All those in favor please signify by saying aye aye those opposed signify by saying nay let the record show that we adjourned unanimously and thank you everyone for a productive morning.