 Good morning, everyone. Welcome to the Green Mountain Care Board meeting. The first item on the agenda is the Executive Director's Report, Susan Barrett. Yes, thank you. I have a couple of announcements. First, actually, a couple of agenda changes. One has already been taken off the agenda a couple of days ago. And that was we had planned to talk about the health information exchange consent policy. We were asked by the legislature to hold off on that. They wanted to take that discussion over to the state house in the House Health Care Committee and the Center Health and Welfare Committee. So we'll be staying tuned and working with our partners at PEDA and with Vital and the legislature on that steps. The other item is actually an agenda of the edition for today. And that is the budget adjustment for two hospitals. They're requesting FY19 adjustments for provider transfer and acquisitions. And they are NBRH and Browhold Memorial Hospital. So I'm looking to the two over there to see where we're putting this. Would it be after the Gifford presentation? OK, I see nodding heads. Is that OK with you, Mr. Chair? It is. And I just remind folks to sign in at the back table if you haven't already. And that is all I have to announce today. Would you like to announce the changes to part 20 of the agenda? What changes are you talking about, Mr. Chair? So we will be starting at 1 o'clock, not 1.30? Yes. Or it may be closer to 1.50. But we will send that out on our press release. And if there are any questions, folks can contact me or Christina. Thank you. The next item are the minutes of Wednesday, February 27. Is there a motion? I'm with the people. I'll second. It's been moved and seconded to approve the minutes of Wednesday, February 27. Do you have any additions, deletions, or corrections? Is there any discussion? Seeing none, all those in favor signify by saying aye. Aye. Any opposed? OK, so we're going to move right into the beginning of this morning's conversation that's dealing with a request from Gipper for a budget modification. So I'll turn it over to the team. Good morning. My responsibility should be a different recommendation than it was. And Gippard sent the board a request for modification on February 14. We had mentioned this to you on February 20. And we received additional donation from Gippard at the board's request. And then the staff was to give you our recommendations. So this particular slide is showing what Gippard submitted for 2018 with 55 million post-budget. Their growth was negative 6.1% and their rate request was 4%. The board approved the NPR, but they put the rate change to 2.75%. The hospital is asking to be increased, reinstated to the 4%. So an increase of 1.25% to be no earlier than much 18. This is incorrect for the 14. They will be indicated effective for the 18. And Gippard is in the audience if you have any questions. So the staff recommends the approval of the 4% because Gippard's first quarter results for the operating margin was a negative 1.6%. The total margin was 1.4%. Their days cash on hand was 210 days. Days payable 41.2. Days in the student was 36.3%. They also, in their documents that they sent us, they had less expenses for the first quarter of 19 at 1.2 billion compared to the first quarter of 18. They also would like to have this increase in rates because of their workforce issues. They may use it as a temporary staff. And also they could have an employee survey that says their employees feel that they have less compensation based on the market. And they also have not recently been raised since 2017. They have poor operating margins where this hospital hadn't been for the last two years. OK, so I do see that Dan and his team are here. And Dan, maybe you just want to address why you feel the need and what you can use it for. And maybe you could just briefly update the board efforts that you've made to reduce the expenses to bring to the mind with the slow, indirect growth. Sure. You can do it right from there. Just do it from there. OK. So as we outlined in discussions I had as well, we are asking for this for two main reasons, as Laurie had outlined. The first being all the pressures that people are feeling in health care across the state of Vermont. And I don't think it's just the state of Vermont and in other industries as well around being able to retain and attract qualified individuals to work in our organizations. It's becoming more and more difficult. I think the unemployment numbers just came out the other day. It was the lowest ever or the lowest in recent memory. Workforce issues are real. We're feeling them. Everybody's feeling them. As Laurie noted, we did not have the ability to provide a wage increase program at Gifford last year. So this is a need that we have to continue to work, to get our, to be able to compensate our people to the rates that we need to make sure that we're keeping up with the market, to make sure that we're able to staff programs. The board is heard from Gifford and from, I think, every other hospital in the state of the pressures we've felt around workforce issues, the need to bring in temporary staffing, traveling nurses, locum physicians, et cetera. We need to get ahead of that curve. We're doing a better job of reducing our utilization of travelers and locums, but we need to continue to invest in our workforce so that we can continue to provide the services that are needed in our community. So a big part of this is to allow us to be able to continue to make those wage, to invest in wages for our compensation for our employees. The other part is, as Laurie noted, our last two fiscal years, have been poor and we are making improvements in that area, but we need to continue to accelerate that. We have focused in three areas. One is getting our workforce where it needs to be so that we can return our services to our historical levels. We are seeing some improvements there, but that takes a lot longer. That's a long, a long range. The second area we've been focused is on our cost reductions and I think you'll see in all the documents that you have around our, whether it's our year end, 18 or the quarter end results that you have for 19, that we've been quite successful in reducing our cost. We submitted some additional materials to the board through this request that give an outline of what we were able to do in fiscal 18 to reduce cost and then what we've been focused on thus far in fiscal 19. Our cost at this point in our fiscal year of 19 compared to 18 are significantly lower than in 19 than they were in 18, so we've seen a lot of success in doing that. Our people are doing an amazing job in reducing expenses and that has had a large part in our being able to make some improvements on the financial end. Our third area that we've been working on is our community outreach. We are doing a lot more in the community, which is important for many areas, but it was also supportive of population health, activities that we're working on and supportive of the overall activities in that area. So those are the three areas that we're working on. Did I cover all your questions? Maybe you might wanna expand on the population health as far as I understand that there's some exciting news with RISE. I'm sorry, the last part? Off RISE, Vermont? Yes, so we, just to go back a little bit, we did join One Care, Vermont in January, so we are now participating for the Medicaid program and we are working well with One Care. We're still obviously in the very infancy of that program for Gifford, but we are working well with that. I can't give you any indication of financial results with that yet, it's just too early. We have had a presentation from RISE, Vermont, and we do feel that that is a very good fit with the services and programs and community outreach activities that we already have in place. We actually think it's an excellent fit. We have decided to move forward and participate with RISE, Vermont. We think that that's going to help us to accelerate our efforts, give us more resources to bring to bear in our community, and we think it is going to benefit our community and benefit Gifford's efforts in that, in that area. So we're quite excited about that. So one thing that's encouraging, at least from the board's perspective, is that you're still healthy on your day's cash on hand, but are you confident that you can bring in the expenses so that you can actually have a positive margin so that you won't have to dip into those? We think we have a fighting chance, yeah. You know, I can't sit here yet. We have four months' results to say exactly where we're going to be, but we think we have a fighting chance to break even or better this year. We are continuing our efforts, and I think I outlined, we have a group that meets on a weekly basis that is working with our staff to generate ideas, to continue to become more efficient, reduce our costs, that is analyzing, getting data to assist with those efforts, and then it's going back and looking to see whether we've been successful and then what next. So we're continuing to do this on a daily basis. We meet on a weekly basis to really bring that core group together on these cost initiatives, and that's something that's going to continue forever for us, so again, I feel quite proud of our group and the work that they've done. If you look at the cost reduction that we have in the materials that you have available to you, you'll see the results of their efforts, and that is going to continue. We do have, our days cash on hand has been relatively healthy. That being said, when you are not generating cash flow from your operations, you have to dip into that, whether it's for capital, whether it's for investments in your staff or what have you. So we don't want to rely on that forever. We need to have a healthy days cash on hand as any organization needs to have, so that's not something we want to continue to dip into. So to your point, yes, we are focused on having our operations be back to the point where we can be generating the cash flow from our operations so that we can support our capital, our other needs, invest in our staff and what have you. That is our goal, and I think, again, we have a fighting chance, yes. Are you currently in compliance with all your bonds, no long covenants? We have two covenants with our bonds. One is days cash on hand, which we have no issue with in fiscal 18. We did dip below our requirement on the debt service coverage ratio, which largely is a reflection of your operations and whether your operations are generating the cash necessary to cover your immediate debt needs. We've been working with our bank. We've been working with our auditing firm, and we are just waiting for the attorneys to finish the paperwork that will provide us with a waiver for that for fiscal 18 and have a new covenants for the next, for this fiscal year. As of now, once we sign those, we will be in compliance, but as I stand here today, that's still in the worms. Okay, and you're kind of uniquely situated geographically when it comes to higher education being located in Randolph with the Montag, but also very close to Northfield. And I'm curious if you believe that your partners in higher education understand the gravity of the workforce, Chauvin and Vermont, and is Gifford itself doing everything that it can as far as clinical placements, because we continue to hear from higher ed. They could actually take more students if they had more clinical placements. So Gifford, so yes, we are in the same town as Vermont Tech, and we're 12, 15 miles from Norwich. We do have clinical placement arrangements with both schools for their nursing students. We work quite closely with them. Every year taking, I can't tell you how many on top of my head, but we are taking new grads from both programs. So from our standpoint, and to my knowledge, they're doing what they need to do, and they're working well with us, and I know they work with other parties as well along those lines. We also are investing in workforce beyond that. Right now we have a certified medical assistant program that we're doing. This is the second time we've run this program where we have people who apply, who want to further their job skills. They go through a program with us where we are providing education, training for them on the job training. We provide them with assistance so that they're ready to take the certified medical assistant certification. The last go-around, we have a group right now that's in the middle of that. The last go-around, we had a number, I think it was five people. They all passed their test. They're all offered positions at Gifford. This group, assuming they all passed their test, they'll all be offered positions at Gifford. They already have designated slots where they will go, and then that wraps up the end of March. We already have plans for another program that we'll do. We've had a number of individuals from within Gifford who said, this looks good. We're interested in it. We'd like to throw our name in, so it looks like we're gonna have another group of people who are ready to jump into that program. So we are actively investing in that, and the need is there as well. Thank you, Dan. Are there questions from other members? All right, the other question on your NPR, and whether your new forecast is realistic. And the reason I say that is your new forecast is up 9% from your 2018 actual. And the information you've given us so far through the first quarter, you're down 5% against quarter 18, first quarter to first quarter actuals. So to turn around and be up 9% for the year, we need to see significant growth in the second, third, fourth quarter. Then the last four years, your trends have been against prior year actuals. It's 15, you were down 7.5%, 16, you were up 1.7%. 17, you were down 1.9%, and 18, you were down 10. And now you're gonna turn around and be up 9% when you're down 5% in the first quarter. So the concern is, I appreciate everything you guys are doing with the cost savings. And I think you are really attacking that. But again, if we have an unrealistic top line forecast, you could continue to have a big loss at operating margin. So I'm just hoping this isn't aspirational. Your first quarter came in at 12.3 million, right? Which would straight line to 48 million, which is what you came in in 2018, and your forecast is 53 million. So are we really gonna get that ramp up? Because I just wanna make sure you've got a realistic number in here. And I think this is something we really should be following up quarterly to be tracking where you are quarterly against the numbers. So we're not surprised by, last year you had a net operating income target budget of 1.3 million and you came in at negative 5.4. So the past two years you've had operating losses. I'm afraid you're gonna have an operating loss again this year, so just, where do you think you're gonna be for NPR? So I would go to the last thing and you see the last part of your question. We are focused on the bottom line. And when you look at how we've been managing our finances over the last several months, we are managing our expenses to our volumes, to our revenues. So as our volumes and our revenues have not been where we expected them, our expenses have fallen trapped. And in fact, our expenses are lower, have gone down more than our revenues have. So we are managing that responsibly. So as to whether it's aspirational though, I don't think that bottom line is aspirational on the NPR. We are focused on our volumes, we are focused on our revenues, but we are focused on the whole picture on a greater basis. What we are seeing right now is we are seeing our primary care volumes continue to ramp up. And again, that's an area that we needed to be focused on in the last few years. As our primary care volumes ramp up, there are more people in our system that are turning to those more traditional values, our traditional volumes that we've had. We have two new general circuits which started in August. They are beginning to ramp up their practice. That does not happen quickly. When you bring in somebody, there's a time period when they ramp up. The last couple months, we've seen that that has gone to accelerated. One of the areas, and I think I noted it in, I think I noted it in, I even noted it in a conversation I had with Chairperson Mullen, or I don't know if it was in the, I don't remember now if it was in what I submitted, but one of the things we're seeing is our, our repeated volume actually has been up in terms of our inpatient surgeries that we've done, but our days are down significantly. They're down 160 days compared to the length of, if you put it the same length of stay we had the prior year, our repeated days would have been 160 days higher. That would have made our revenue and our net patient revenue higher than it is now in what you're seeing, but it's the result of something good in what we're supposed to be doing, which is to be lowering the cost of care for people in our communities, getting people on their feet and out of the hospital quicker. So all good things, but on the revenue side, on the net patient revenue side, it shows up as a negative. So, you know, we're doing the right thing and we're gonna continue to do that. And again, we'll be managing to our bottom line and I feel confident that we'll have better results as because of that. We also had, thank you, Jeff. We also had some equipment issues in our OR and our endo system was down for a couple of weeks and it was two to four weeks over the first quarter. That had an impact as well. That's back up, we're back at full speed there. So we had some things that happened. You know, we think our net patient revenue is going to continue to be higher and we'll continue to come back and talk with you about that. I will say that one thing that's been helpful to me and I hope helpful to the board, the communication, the regular meetings have been better. And that's, you know, I think a good effort on both sides. We'll continue to do that and we'll let you know what we are experiencing on a weekly basis, monthly basis, whatever makes sense. Thanks. Other questions? Tom? Just a couple. Your list of savings opportunities, which was truly impressive. I mean, this down to $100 items. So it sounds like you scrubbed things pretty well. But one that I noticed that you didn't book was your low census staffing that was, I'm just curious as to where that stands and what savings value that might be. So that is, we gave what the FTE savings was on that. It's, it would be 6.8. So again, as I mentioned in the previous question, we're looking at managing our expenses to our volume. So if we're seeing that our inpatient volumes are really low, we're instituting low census, which means that we're calling some people off. If we know that we have two surgeons on vacation in the humming week, again, we're doing the same thing. And it's not just in the areas where, it's not just in the nursing areas, it's not just in food service or nutrition services. We're taking time off if we're seeing that that we're gonna have low volumes coming up and whatnot. So we could go in and get the dollar amount on that. It would be, you talked about really scrubbing, that would be really scrubbing. So we went back and looked at that so that we could at least mention it in this submission. But it's a fairly complicated math that we have to go in to look at it on a person-by-person basis. And just because of time constraints who weren't able to do that, we can continue to try to track that better for future. But when you look at the amount that our expenses are down in the first quarter, it's in there and that has a profound impact, but I don't have a dollar amount for you today. Next would be, in terms of your non-operating income, it looks to be a fairly large bump over the 2019 budget from the $849,000 of 1.2939 cent increase. And I understand non-operating income can fluctuate, but I'm just wondering if that's your current projection, what risk is there that you won't achieve that? I'm sorry, we're just looking through pieces of paper here. The non-operating or the other operating? Non-operating. It's just the investment impact. It's what I could be bothered about. Always, yeah. And my eye is just, as you know here, I notice that your proposal doesn't include any additional revenues from Medicaid. Is that because Medicaid is a, you was a hospital or a price taker, or is that because of your enrollment in one care, and now you have kind of a fixed Medicaid payment going forward? So, other questions, Robin? Thank you. I wonder if you could just speak briefly to the retirement community, because I know that that's been a little bit slower to ramp up than you had been expected when you had previously filed for the CON, and that seems like that is a budget pressure that you're facing. So, that is not reflected in the financials for the hospital side, however, obviously, given our discussions about that, when we discuss the day's cash on hand, that's the day's cash on hand for our entire organization. So, as we're ramping that up as expected, as you are filling a program like that with residents, we are relying on our reserves and our day's cash on hand to make up the difference while we're filling that. So, we are around where we had targeted, we would be at this point in our budget year. On that, in terms of our residency, we are still in Phillip phase. We are the winters, as any of you have been in Vermont for a while know, real estate doesn't move much in the wintertime. So, that is normal, that we're seeing that right now. It's a little slower the last couple of months. We're seeing increased activity in terms of people acquiring, in terms of people coming in and taking a look. We have some people who are committing to come in in the next couple of months. Hopefully it won't be too muddy, but despite that, we're looking at that ramping up in the next couple of months as well. Again, we still think we've got a good shot of hitting our occupancy figure, which at the end of the year, we were expecting to be at 30, which is about 60% of full occupancy there. So, we think we've still got a good shot at that. So, we're about where we thought we'd be at this point in the budget year. Does that answer? Yes, thank you. So, thank you very much. I appreciate a lot of the cost saving efforts that you're already undertaking. And the rate request feels to me like a short-term stop-gap measure to improve the margin and to help address some of the workforce issues. But I wondered if you could just talk briefly about some comprehensive long-range strategic planning that you might be undergoing to determine honestly which services Gifford can effectively provide at low cost and high quality. You mentioned ortho. One of the things we've learned in our ortho panel was that one of the ways to really reduce costs is having economies of scale and leveraging volume to be able to bargain with vendors to get implants, for example, at reasonable prices. So, given that Randolph is an HSA that tends to be in the high end of total cost of care, I'm wondering what a long-range plan you're doing to think about service lines and what's appropriate to be doing in Randolph in, say, five years from now, that also may help the hospital become more sustainable. Yeah, so we do have our strategic plan that we adopted about a year ago, our most current strategic plan. We're doing a number of different things in relation to our service planning. One of the things that I think Kevin Mullen mentioned earlier, our geographical location in regard to the colleges. Randolph is in the, I think it is, the center of the state, the geographic center of the state. We're also in between the two larger tertiary care hospitals. That works in our advantage in that we're able to work with them to partner on some of the services. For instance, we partner with Dartmouth-Hitchcock on cardiology. We partner with them on our orthopedics. We partner with Central Vermont and UVM on oncology and pathology and other services. So we are not in a situation where we're trying to do everything ourselves, but we are looking at what core services are appropriate for a small community hospital, for a small community. Keep in mind that where we're situated in Vermont is amazingly beautiful with all the mountains, but those mountains can make it very difficult for travel as well. We have an older population. We have, I think a percentage of our population that where transportation is an issue as well. So there's a core of services that we want to be able to provide in our community. So we are working with our partners to do that. We're also investigating what is available in terms of telemedicine services. Again, so that our people in our community don't have to travel as far, but they're able to access more specialized services. So we are working on those areas as well. We are, I think a big thing for us, and I think probably every hospital would tell you the same thing. We have been working to get out of the mode of just trying to find the next person to come in for any position, but particularly for our physician positions. We're looking for people who have some tie back to our community, and I would say our community, meaning Vermont in whole. People who have interests that are aligned with what's available for their family, for themselves, what they like to do. That approach, we've seen some success in utilizing that approach. It's a slow approach, and we are, this is gonna take us a while. We're not just gonna snap our fingers and have all of our positions filled and have everything coming along at the same levels we've had in the past. It's gonna take a little bit of time, but we're seeing that those success is there, and that's what we're gonna continue to do as well. So we are able to fill those positions that we need for those core services in our community, but we're filling them with people who are going to have a long-term connection and who are going to stay. We just celebrated the retirement of one of our pediatricians who've been with us for 43 years. Is that Ludinicola? Yeah, it is Ludinicola, and it's retirement in quotes. He's never really gonna stop being involved, but you're not gonna see those people who are staying for 43 years, like you did in the past, but we're trying to find people who are going to make that connection, who we can get to stay here for 10 years, for 20 years. Our community needs that, they demand that, and they deserve that, and that's been our approach. One of the things they had, there were only three FQHC hospitals in the country, two of them are here at Vermont. One of the things that surprised us in Springfield was the operating losses being experienced by the FQHC site physician practices. What's the financial picture of the effort on the FQHC practices? Improving, we, you know, again, I would be careful in, for me as one person, I'd be careful in making too close of a distinction there with the FQHC primary care relationships in the hospital, because most hospitals have primary care, and I think the larger context, the larger conversation is that primary care is incredibly difficult. And if you just look at primary care as a single service, in general, it's not going to be one that is going to generate a positive operating margin, but if you don't have primary care, you don't have a healthcare community, and so I would just caution to look at it from that standpoint. We have had, this isn't news to the board, I've talked about it numerous times, I'm sure my predecessor did as well. We had, like a lot of people, some difficulties of primary care in that we had a number of retirements, we had a number of people who left for other positions, we had some people who left primary care, and we've been building that back, and we've been seeing that improvement, we've been seeing our volumes and our revenues increasing, at the same time, we've been seeing our costs come down because of the amounts we've been making there, so we've seen significant improvement over the last couple of years, and we continue to see that this year as well, and say we're doing well. When you're open for primary care, Doc, what's the starting date? Really going to make me answer that. We look at a range, yeah, it depends on, I'm going to try to get out of giving you a number. I'm just going to be honest about it. We look at a range and we mark that to Medical Group Management Association Surveys, MGMA. We mark that to what we're hearing in the community, and so it's increasing. I think MGMA says the median for the Eastern area of their survey is 215 or 220. We also, we look at FQHCs, which tend to be lower, lower than that, but then you look at some of the larger hospitals or health systems that I think they tend to be higher, so we're trying to mark it in the middle, we're trying to be competitive, but we also know we can't hit that high end, and our volumes are not going to be what they are in suburban or urban area, so we have to be realistic about that, and again, we go back to trying to find people who want to be in that kind of community, who want to be like our physician, Ken Borey, had talked to the Senate Health and Welfare about. They want to have a situation where they're caring for four or five generations of the same family who want that kind of care, so those are the kind of things we're looking for. Probably not going to win a lot of the money battles when it comes to compensation, but we need to be competitive, and we need to attract people who want to be in the kind of community, in the kind of healthcare organization that we are, and we think the FQHC with a hospital actually is beneficial to a lot of people who are looking to work in primary care, so we do think that that's a positive thing. Okay, any other questions? If not, is there a motion? I hadn't thought about this, but I'll make it up if we go along. I move that we accept the staff recommendation relative to the increase in GIFR's NPR. This is just a question for the chair. It's actually a commercial rate. Well, it is a commercial rate, but I know that I'm just wondering. It doesn't have anything to do with NPR. It's an increase in NPR. Well, the three components of this thing were the commercial rate increase, the Medicare increase, and a bad debt, and those add up to the 286,000. I want to approve, you know, make a motion that we approve that, but is it just, does the motion have to be just simply tied to the commercial rate? I believe that really the motion should be to modify the budget order to add the additional more than a quarter to make it a 4% commercial rate increase from the previous year. Okay, then that's my motion. Is there a second? I'll second. Is there discussion? I just have a comment I'd like to make before we vote, which is that I want to applaud Gifford for taking a proactive approach and actually coming forward to discuss some of the issues that they're facing as well as making the amendment request. I know that can be a hard thing for hospitals to do, but I really think that that openness to have the discussion is incredibly important. And I know that's hard to do in a public forum, but as the regulatory body, it's important for us to have full information about the current financial status, which is also obviously a requirement of the oath that's signed by hospital leadership. The pressures facing small rural hospitals are obviously not unique to Vermont. There's been lots of news around closures of critical access hospitals in other areas, and we've been fortunate in not seeing that happen here yet. But I think we can't be blind to the fact that these are national pressures that Vermont hospitals are seeing as well as of course some pressures that are unique to Vermont. As noted by both Jess and Maureen in terms of what we do in this process around the NPR, not being aspirational and the commercial rate being a limited tool, I just want to emphasize for myself that I don't think the hospital budget process alone is going to solve all of these pressures because as Maureen said, if the top line is aspirational, that's not going to magically make that revenue come in. And as Jess said, our other real tool is the commercial charge. And for hospitals with a patient mix that is heavily weighted to Medicare and Medicaid, that's a limited tool. I personally don't believe we're going to be able to cost shift our way out of financial challenges to small rural hospitals. Vermont or just don't have the ability to absorb that in the commercial premium area and to reinforce point that Jess made in her question, I think as we move forward in healthcare reform, as we move from volume to value base, that is going to require creativity, forward thinking and a willingness to really take some operational focus in the long term in order to really shift the what we're doing in our small hospitals so that it reflects realistic volumes for our very small population as a whole. So thank you for letting me just take that comment. So Tom, one thing that probably should be added to the motion is effective nowhere earlier than March 18th. I would second that. Does the seconder agree with that? I agree as well. Okay, any other discussion? If not, all those in favor of the motion signify by saying aye. Aye. Any opposed? I want to thank you, Dan. You know, the communication has been phenomenal between you and the board and we appreciate that and look forward to having the continued updates and we wish you the very best in your progress in trying to control expenses and maintain a great institution. So thank you very much for everything you're doing. Thank you very much, Bob. I appreciate it, this is Mark. Okay, team, let's move on to the next item on the agenda. I have a question for Chancellor. I'll be walking you through North Eastern Vermont Regional Hospital in Brattleville, Memorial Hospital's request for persons here at Y19 to the budget as a result of provider transfers and acquisitions in their communities. So to kind of provide the framework for this discussion, I want to just read quickly language from FY19 Magic Guidance, Vermont Care Board's Magic Guidance. When independent providers move from outside of the hospital system to within the dollars associated with the provider practice also should to the hospital. But these are not new dollars in the overall healthcare system. They can have substantial impact on the choir hospital's budget and NPR and must be appropriately accounted for in the Vermont Care Board's review process. So under this provision of budget guidance, both hospitals have requested that their budgets be amended to reflect the acquisition of practices that were previously provided by independent providers in the community. So first, and this should all of familiarity to the board. You've been provided this information previously. So the first is NVRH. They have acquired a physical therapy practice. This practice was independently owned and no longer able to operate in their community when the owner unexpectedly passed away. So the hospital purchased this practice effective December 1st of 2018. There are 10 full-time employees comprised of four physical therapists four physical therapists assistants and one support staff and the hospital expects that the level of services going to maintain from an independent practice to a hospital-owned practice. Based on actual variants for FY17 for each hospital and the blueish gray bars are the budget's actual variants for FY18. Moving on to outpatient visits. Again, same format. The system change budget to actual variants for FY18 was 0.9% and for your framework reference FY17 the variants was a negative 0.8%. With the ranging results from a negative 5.2% all the way up to a 52.0% increase. All the way up to a 60.2? Yep. Yes, I'm sorry. And that one, the Prattle World, that was a preliminary number. So I think that's why I didn't call it out on this one. Okay. Sorry. And this is just a visual representation of the multi-year look. Showing again, green bars that FY17 budget to actual variants and the grayish bars that FY18 variants. Moving on to the second to last section which is the key financial indicators. We asked hospitals to submit lots of financial indicators and we selected six for this presentation. Again, all those financial indicators are in the hospital or packages that are located on the website. So the three that are displayed on this, we've asked for six. There's three on this slide, seven X. These cash on hand operating margin and total margin. And kind of just to ground you in these symbols if there's an arrow pointing up it means that increasing values are favorable. So the bigger the number, the better. If it is pointing down, it means the smaller the number, the better. So for example, these cash on hand, there's the column that shows the FY17 results as of September 30th, 2017. So these results are specific to a point in time. So it's the last day of the fiscal year. So comparing FY17 results to FY18 results and then the difference between the two. So if it's a number like Dave's cash on hand, those are days. So the 195 days we got around in 17, 196 days and 18 of the differences one day. If it's a percentage like operating margin and total margin, it's the same approach. The presentation 2017 compared to the 2018 result and the difference between the two. I just wanted to make more relation on this chart to chart 17. Can you go back to 17% of it? It makes me think of perspective budget to actual. Oh, budget to actual? Yeah, budget to actual. There is a difference in our page numbers because this presentation is all four combined. So we're looking for budget to actual for NPR. Yeah, budget to actual, the two year variance. This is the graphical look. Right, so what I would do, we have that graphical look. So if we look at the five hospitals that have missed their budget for the past two years, Grace, Springfield, Gifford, Rattleboro, and Northwestern and then there's a couple others that have missed a bit. Copley, one year, CMC and now go to the slide that you were just on. All five of those hospitals for the past two years their operating margins have been negative. And the other hospitals with Copley, CMC, they at least had one year that was a miss to their budget forecast. So just trying to correlate again that these misses when we miss the top line and some of them are pretty significant, it falls to the operating margin. And when they've had year over year misses from budget, that is gonna be something we'll look at in the budget process again, to make sure that we're not gonna run into situations. Those hospitals also tie to some of the ones that are most financially challenged as well. I'm kind of following up on Maureen's line. One of the things that is most troubling is when you have huge out of adjustments and we sell one hospital with over $4 million out of adjustments and that comes to us very late. And I don't know if we ever really be able to resolve those issues or catch those issues because we're dealing with information that is given to us. We do not go out and field new audits. And it's just something to throw out there for consideration that we're gonna have to, at least consider what could be done differently so that we don't have a situation where Dave's cash on hand could fluctuate so greatly in such a short period of time. The next section deals with five year results to show kind of some race point year over year for both operating margin and NPR. This next slide shows the next three categories of financial indicators that we've selected, days payable, days receivable, and debt service coverage ratio. And as Kelly mentioned, there's a glossary in the back that shows the definitions of these but more specifically the formulas that the hospitals use to calculate these indicators. And then five years on. Okay, so this section here, we are providing a multi-year look for the budget actual variance by category. Well, so this is the same format we're going to use on the next two slides. We have the hospitals, again, in alphabetical order. We have actuals from FY14 through FY18 and several of the serving, and so the fact that the data collection process has changed over time, this explains a lot to me. So that's the end of the numbers piece. We have included this short two-slide glossary to help readers with definitions and formulas. And we also have, if you're interested in additional definitions and formulas, you're welcome to look at our user reporting manual that goes along with the budget guidance on our website. It's very lengthy and exciting. If you're interested in more confirmation about the hospital budgets and how things are calculated within our reports, that concludes the actual results presentation. Thank you, team. Clearly, when you look at the numbers, we have a large number of hospitals that exceeded the variance that was allowed in the previous year's guidance. I think we're scheduled on the 27th, is that correct? Correct. To have a discussion on enforcement, but at some point, we'll have to have a discussion on, I think it's called last year, I think it was 2% final discussions. The guidance had a half percent next year's proposed guidance, although it hasn't been going on, has that increased to 1%? So one of the items that we'll have to talk about as a board is what percentage of the variance are we going to use for our discussions on the 27th? I'm just throwing that out there so that people are thinking about that as we move forward. How would we present off the percentage of the budget? Brokering. Next is the hospital budget guidance. You know, I guess maybe we probably should just open it up for public comment, since it's really two different topics and we're probably putting it all together. Is there any public comment on the actuals or is there a public appeal? So a comment and a question, Mr. Chairman. The questions are, I think it's a huge hole here in which it's all been spending in darkness, which really drives with everything that's happening on the East Coast and it's really squirrelly over there. And that's obvious for what time I'm saying, on what Reed's saying, what Jess is saying. And so I'm just curious whether there's something the board can do that's filling this big gap because I don't think you can get something like Cosper Captain in the service area without knowing what's happening on the tertiary end. That blocks you out from that piece of insight on the whole West Coast, I mean East Coast. So I'm just curious whether there's anything you can do. You don't have any legal hold over darkness, you do have a legal hold over one care of a month and darkness is an owner of a one care of a month. So it just seems to me that somebody's got to do something about filling in the picture so that you can stop and figure out, I know what Tom's looking for and it's obvious what Marlene is saying, it's obvious what Jess is saying. I don't think you're gonna get at any of that unless you can start getting a grip on darkness. That's just, so that's a question. Sometimes I think you read my mind, but it has been one of the most frustrating things when you see such a large percentage of our healthcare costs being exported across state lines and not being able to really weigh in on that. It is troubling. We live this, I think it's worth the try, Mr. Chairman. We agree obviously, but the current CEO of one care of a month is in fact a Dartmouth person who's highly knowledgeable and understands not only one care but fully understands no Hampshire, which is also a piece of this. There's a little string of pearls on the east side of the Connecticut River, just as a string of pearls on the west side of the Connecticut River. I just think that somebody ought to muscle the Dartmouth. I just make a point, which is we do actually get the spending data through claims. We don't get the financial metrics from the hospital, but if it's a Vermont resident, we would have in vCures any spending that occurs at Dartmouth. So we do have, because that comes from the payers. So obviously there's other polls in vCures like the self-insured issue. So we're not totally blind, but I think to your larger point, we don't have a regulatory lever, certainly, to require reporting. We did, I think, last year, request if Dartmouth would voluntarily come in and talk with us on what you're doing. And my recollection is they declined. Well, can I just ask something? Is any of that data, which you might call indirect or partial data from Dartmouth, is that integrated in any of this analysis? Not in this, because this is by hospital, right? But if you look at the, we get other sources of data, like in the ACO program, we get the information of more of a claims basis, too. Okay, but then where does someone, anyone, where does someone get a look at the full analysis of what's going on in the system? I can figure out the West from where I got my hand. I can't figure out the East worth of who. As Robin says, it's really in the expenditure analysis, but it's one of the frustrating things as we try to hold hospitals accountable for total cost of care in the health service area. One of the frequent retorts from someone that may be at the high end on total cost of care calculation as we look at the data is that that's because of movement to tertiary hospitals like Dartmouth. And so, you know, we continue to try to evolve and try to get better, but I don't think we've claimed and figured this out. Thank you. Other questions or comments from the public? Okay, let's move on. Guidance. Upstate of the previous presentation on February 20th. We will be going through a summary of those changes who reviewed non-financial reporting guidance that you've ever thought that we'll be able to ask the hospitals for in April. Mention the public comments we've received today and then the next steps. In the narrative, we have added a change to a appendix, which is going to be asked for hospital's responses to this particular table. It's an all-care, total cost of care table and the questions that we'll be asking are on appendix 11. I will show you the appendix in a few minutes. We're asking hospitals to let us know what they think could be improved in our view of the total cost of care and the HSAs. Maybe Jess could help me out a little bit on this one. Help you out? Okay. So this is a response I think about when Patton's still here, when the team presented the hospital funds in the first round, I had requested that we move, take a baby step which was trying to start to align hospital budget process with the all-care model by pulling together some measures of total cost of care per capita at the HSA level, which I think is what this is the first pass at doing over time at the HSA and looking at absolute level of total cost of care and growth over time. And the point was to start to unpack some of these numbers, recognizing that there's lots of caveats that there's not a one-to-one mapping between the total cost of care in the community and the HSA and the hospital spend or even hospital services. But how do we, with all the caveats in mind, that I think there's plenty of caveats that were put in the budget guidance around what this data shows and what it does to show and what are the factors that could go into explaining total cost of care, whether it be demographics or whether it be care mix, whether it be services offering, whether it's data state spending, all of these types of factors can explain some of these measures. But to the extent that at the end of the day, Vermont is gonna be held responsible for this total cost of care per capita at the state level, we need to start to understand what's happening at the HSA level. So the request was to put it in the hospital budget guidance as an appendix, similarly to what we did a couple of years ago when we put the quality measures in and asked the hospitals to respond to what do they see happening in their HSA related to quality that we're being held accountable for. This is the corollary to that to say, these are the total cost of care per capita measures in your HSA. Can you talk to us about it? If your HSA is above the state average, help us understand why. If your HSA is growing at greater than 5.5%, what we're gonna be held accountable for, can you help us understand why? And are there, you know, this is our first pass of trying to understand what's happening in HSAs. Is there a better measure? Is there another way to look at this to better align the hospital budget with the all-hander model? So it's an appendix. We would love some insights from the hospitals in their HSAs. Is that a helpful explanation? Anybody else wanna add to that from our conversation board a couple weeks ago? It summarized well. I guess the only thing I would add is to your point, Ham, this data would include Dartmouth, although, again, the speakers would exclude self-insured employers. The next changes that we have is under the Gledge of Performance Enforcement, or Enforcement. We are changing the length a little bit to go back to the rule. Where we are on the paragraph six, we are changing the term rates to charges. We are taking out in the seventh to 20th year over years to be years. And we're adding back a lot of hospitals to retain a percentage of all of the surplus funds. And F is any other actions that board games appropriate. So we're basically changing it back to what the rule was, the budget guidance. Then we've added appendix, like I mentioned, appendix 11, the total cost of care table. We've changed the appendix for asking for a modification to your budget. Basically like what Dartmouth and Springfield were asking for. We've kind of simplified it and made it a little bit more understandable. We changed the terminology about modified budget requests. We're asking them to put it into an Excel, a updated full year financial projection for fiscal year 2020. And added the sentence provide information on impact with proposed increases in charge on gross revenues as well as NPR. And then the other updates we did, they were not available the last time we've added both for the board chair. And then we received the questions from HDA so they are getting the documents now. Any questions? Then we have the April non-financial reporting. We hope we will have an approval today and we'll send them out to the hospitals. This is about quality improvement related to the all-pair model. Access time and wait times and your community health needs assessments. We are asking the hospitals to submit their data by the end of April. And we as sports staff will be summarizing those answers for you so that you'll have them available when the budgets come in and in the summer. Do you want to add anything to that? So I do believe that what you're seeking today is board approval for the April reporting templates and hopefully we can vote on that this morning. So. Thank you. And we wanted to let you know we received public comments from VOS. The public comment centered around guiding principles of the boards, the narrative requirements and the input policy. The UVM asked for us to take into consideration better benchmark for the academic medical center for basically we're looking at benchmarks anyway so we'll be improving them in the future. And then the Office of the Health Care Advocate was around patient affordability and possible costs. Then we're asking for your vote on the non-financial reporting guidance. If you have any more revisions to the guidance and also on the last time when we met there was 3.5% MPR growth target and the year over year change that was going to be for 2020 to 2021. So two year 3.5% target. And we are asking the board to vote on the guidance finally by March 31st because we have to by statute give them out to the hospital. Hopefully we can do that vote on the 27th since the 31st is not a board date. If necessary we'll have an additional meeting. I'm going to open it up to public comment before we start to walk through the next steps just so that we can the board can actually vote on the non-financial reporting guidance for April. So at this point I'll open it up to the public for any public comments or questions. Yes, sir. Hi. Anybody? Mike, I'll try to open the hospital association. So in looking at the new guidance as it's been presented specific to appendix 11, I think that one, you know, directionally this is the right sort of way to go. I wonder if this is the right place for these types of questions. Clearly the caveats placed in the appendix 11 guidance recognize that this is not completely the hospital numbers and all of the challenges around capturing the pharmacy piece, the self-insured piece, and would suggest possibly moving this out of the the current guidance to potentially the ACO budget process and or another vehicle. I question the relevance of this information when you'll be making decisions on hospital budgets which are more evidence and fact-based in some of this information. So I appreciate the opportunity to comment. And will there be a new comment period posted for this because this certainly hasn't been discussed with any of our members? So I think we have time to have a public comment period so we could post that at the end. So yes, we'll have a week of public comment and that's a little bit of an update today. Thank you. And again, as we outlined in our comment letter last week we certainly appreciate all of the dialogue, the communication that's happened between your team, your staff, it's been a really, really great process. So thank you to all of you. And likewise, one for all of us that participated. It was a great number and a great dedication to the work. So thank you. Any other public comment? I'm from the University of Vermont Health Network. I would welcome the opportunity to work with the board and the board staff on what an appropriate benchmark is for an academic medical center. And I just kind of wanted to share where the concern was with putting it out. My interpretation was appendix four was to give a guide as a financial health indicator. So my comments are coming from that perspective. And if you look at the 98 days cash on hand there and if you look at the S and P metrics that's below a triple B or rating. So it is triple D minus and below. That's a non-investment grade hospital or it's considered a junk bond status hospital. So there's a lot of concern there. This benchmark is put out there, particularly from a day's cash perspective. So I would welcome the opportunity to work with you. I think putting a benchmark out there for an academic medical center that is below an investment grade and giving that the appearance that that is a financial help of an organization meaning an organization that is doing well. I think that's very, very misleading and I would welcome the opportunity to work with your staff on what a more appropriate benchmark is for an academic medical center. Speaking from a subtle only mark, I do want to agree with you and I'm sure that the staff is more than happy to work with them and try to figure out what that appropriate benchmark would be. And I think this goes to some comments earlier that not one benchmark fits all and I think this is one of them. So, likewise, I think for the critical access hospitals probably deserve their own benchmark too. Thank you, Mark. Other members of the public? Seeing none, is there a motion by a member of the board on approving the non-financial April reporting guidance? I can move approval of the non-financial reporting guidance to be issued before approval. Seconded by member Holmes. Is there any discussion? If not, all those in favor, signify by saying aye. Aye. Any opposed? Thank you. So, as noted, we have a public comment period and we will likely be looking to have the actual vote on the revisions to the guidance on March 27th. Is there anything else, team? Not at the moment. You're doing incredible work and you haven't missed a beat. So, very much appreciate all the efforts that have been put in and I think the data was very useful to the board. We look forward to the continuing discussion on these issues throughout the rest of the month. So, thank you very much. Sure. Go ahead. Just one thing I want to talk about amongst the board as far as the guidance for NPR, we have put out last time the 3.5 district guidance and we're just getting the actual 2018 results right now and looking at the past two years and the current budget. The budget for 19 is up 2.8%. 18 was up 3.1%. 17 was up 2.8%. Looking at all the hospitals over the past two years, since we're also looking at the two year guidance, only three of them have exceeded a 3.5% cap over those years. So, that was not a Scottney, Northeastern and UVMC. So, one thing I wanted to talk about is potentially proposing a range, whether that be like 2.5 to 3.5 or making some, kind of blocking ourselves in for 3.5% for two years. We haven't needed that for the past two years. We haven't needed that in the budget this year. It's growing the number instead of addressing one of the things that we wanted to do, which is controlling that number as well. And I understand the 3.5 ties into the total cost of care, targets, but those targets include a lot of spending outside of the hospital spending. So, I'm just trying to, we can only do this in a public forum. We can't talk about it privately. So, that's why I'm bringing this up now, but whether putting in a range or something to give a little more flexibility rather than locking into one number over the next two years, which is a bit higher than what we've actually trended to. And I know what some of the issues are there are that certain hospitals are not gonna hit for 3.5%. They haven't historically, it would be a challenge for them to get there. And the key lever that they use to get there is the commercial insurance rate. So, I do also wanna put out there as well. We will once again be looking at the, I certainly will let the commercial rate increases are that people are submitting because if we stick to a 3.5% for the hospitals, and we actually had some hospitals last year specifically say I could have put in a higher number and still been at the 3.5%. And that's not what we wanna use that lever for. We still have to justify that separately. And the concern is putting out a higher number for hospitals that will not get there is gonna present some issues potentially on where they may go with commercial insurance. On the other side, there have been hospitals that have exceeded that number every year for the past three years. And I think that does need to be a consideration as to where they would fall in a given year. So they were trying to be at the higher end of that three and a half. So it's really to open up a little more flexibility for it. So I just wanted to see if any of the other board members have any comments. So I guess I'll start with the comments. The reason why I had to pose the 3.5% over the next two years is to create some certainty moving forward for one, but more importantly to allow hospitals to make the investments that are necessary after moving away from fee for service to value based on the person. And the time to make those investments is as soon as possible to try to get future savings in the system. And the third point for that number is looking at the incredible workforce pressures which have been so well documented. There are such a daunting challenge for our hospitals and medical professionals around the state. And so I don't think I ever viewed 3.5 as telling everybody to come in at 3.5. I'm not sure if a range of 2.5 to 3.5 does anything different than just setting it up to 3.5. Because I think that we're gonna have to be realistic on those hospitals, especially that they have a trend moving that shows negative NPR trend. That's gonna have to be addressed and we're probably gonna have to do that in enforcement which will be coming up shortly as well. So at least for me, I'm comfortable sticking with what had originally been proposed by me. So obviously I should be comfortable with it. I can understand some resistance to the 3.5 over the next two years. I am comfortable and I think it's a good thing just for people to be able to look down the road to have a two-year market. But there's some things I worry about that in terms of the all-care model, here we are in 2019, which is the second year of the five-year run toward the 2022 end. And if you look at these, for example, these operating expenses and NPR for the five-year results, the averages for both of those across the entire system for the five-year trend is 3.8% for NPR and 4% for operating expenses. What I worry about is that we make a mistake and get too far away from our 3.5% target and we find ourselves in 2021 and 2022 not being able to rein it back in. So I mean, obviously there's a lot of moving parts there, but I would feel more comfortable with a range maybe doesn't go as low as 2.5%, but in the 2.7 to 3.5% range and to have the board have some discretion. We don't have real visibility on the 2019 now as we only have a few months or a couple of months to three months worth of data. But by the time we're into the budget process we will have seven or eight months of data on 2019 which will help inform our conversation. And so I'd like to get to that point before kind of locking in maybe over 3.5 compounded over two-year target and maintain some flexibility in the system so that we can adjust. We have a long-term goal here, a total cost of care 3.5% statewide and we're still in the first half of that season. And I think to kind of block ourselves in would be a risk that some of the bigger players and as I noted earlier, the network players are 60% of the pie. If things kind of pick up, we'll mention that we can't pull back then it risks success for the all-parent model, I think. So in looking at the actual budget guidance language, what it currently says is that the board established a X% growth target for hospital, NPR and fixed perspective payment. I think if we said established a maximum X% growth target that kind of addresses the issue. Because I think at least for me, I'm good with the 3.5, I think it gives room to address some of the workforce challenges and investing in larger, more aggressive operational shifts that I wouldn't expect quite frankly to see this budget cycle, but this has to be a longer term planning project. But I think it has to, the planning has to start now given what we're seeing in the financial results, where quite frankly, the growth is modest, which is I think kind of a system what we're looking for. But we are seeing year point worrying expenses going out much faster than revenue. And I don't really think the way to deal with that is to increase the revenue because then we're right into our same affordability crisis. But I think that, so I do think, I agree with Kevin that 3.5 is a maximum and it's not a guarantee to your point worrying. The guidance then goes on to say that hospitals need to consider their 18 and 19 results and that we would expect that their request would be aligned with those results. So I think we might be able to clarify the language in such a way that kind of gets to what Maureen and Tom are talking about in terms of ensuring that there's, that we're not continuing sort of aspirational budgets and that there's some reality there. So just a thought. Yeah, I just wanna comment. It aligns to the 18 or 19 if you're falling below. Yes. Not if you're at the ceiling. That's true and I do agree that one of the ways that we have been enforcing overages over the past couple years, there's really been two tools that I think we've been using. One is limiting commercial rate increases the next year to kind of offset positive margins from growth over the approved budget or adjusting then the NPR growth in some other way. So I guess I'll just echo some of the comments that are already, which I think is that I think we can tweak that language just to address the fact that I think it's an upper limit and some maximum. But for the reasons that have already been outlined in terms of there are operational investments that have to be made to switch from all air, there's workforce shortage issues. I think that we wanna give some head room but I think I do hear what you're saying, Maureen, in the sense that we don't wanna be seeing aspirational budgets that are some hospitals that are not gonna hit three and a half. We don't sew it. Saying that that's the maximum does not mean that they expect every single hospital to come in at 3.5, I think that doesn't make sense. And so my hope going forward, and I think there is that language about looking at their actual performance and submitting a budget that's realistic and non-aspirational. I think you really need that. And we're gonna be looking hard at that when we see the budgets. And I also agree with your point, Maureen, about commercial rates. So we are gonna be looking at commercial rates and they may come in under 3.5 but if they're asking for a commercial rate increase that seems out of line with medical inflation and other sorts of measures, then I think we're gonna be looking at that. So to your point about the two year, one of the things that I think I would say and I'm not sure this is actually in the budget, guys, it's been in my mind that if a hospital comes in over in one year, the hope would be that they might adjust if that's possible in the second year. So 3.5, you know, they could see it in one year. We may be looking more carefully in the second year. And it may not be a 3.5 in the second year, we're looking all the time. So I think maybe it is possible we could be tweaking some of that language in there to give the board some flexibility that Maureen suggested. So I think if we put the maximum in there, the maximum 3.5, I could live with that. I think not really hearing that people are looking for the range, so. So just to be a voice of caution, having a concrete maximum could place us at odds with what we've always told hospitals to come to us with your individual story. We've already had two hospitals communicate with us about a huge increase in volume over the last few months. It's been a tough winter in Vermont. More importantly, we've always sent the message that if you can explain to us that you're bringing any business from outside the state, bringing it back into the borders of the state, you can document that, that we would be willing to consider that change. So I just worry about what the language might say when you just say maximum. Yeah. I agree with everyone's concern. Obviously everyone wants to try to keep growth in line. I just want to be careful that we don't make a mistake as we try to figure out language to put in. Well, maybe Mike and I can put our heads together and try to come up with something that kind of represents because I think we could also add some language, indicating that of course, we would take into consideration individual circumstances. So any hospitals requested something over the 3.5 that would please justify or something like that. I think with those tweets, maybe we can find language that everybody can learn with. Yeah. And maybe Mike and I can try and do that. It may make sense since we have another week for public comment, we should get that at least a draft posted so that folks can have a chance to look at the comment very closely. Thank you, Robin. Are there other comments from the court? Any other points of discussion? Is there any comment from the public? Pam. I'm trying not to be negative here, but I think that you're pushing on a string with the 3.5. You have to do it and it worked pretty well so far, but the reality is that you're not going to be able to get the whole thing operating in a sustainable way until you deal with a question of service mix across the whole system. And you're not going to be able to do that without being able to see, start seeing cost per capita numbers in the service areas. That's really the new reimbursement side of system-wide data. And so unless you can, until you do that, until you can see what the cost per capita in each service area is, you're not going to really know what to do in Europe. I know that you're working on that. I mean, I know that you're- Well, we have been actually seeing it. I think one of the slides that you grew up had some data. The question is, is the data completely reliable? Are there reasons that a hospital can't control the expenses on their service area, things like that? So it gets tricky because no one would rather move more quickly to a per member per year or per member month basis for this type of discussion that we're having as far as guidance more than me. Because I think that's really the key question. But the question, the reality is that you're, on your scale target, your deadline, as Robin has made clear many times, is 2022, you're now putting together what's going together now is the 2020 budgets. You can't get that into that. You can't really get at it in this budget. So then you're looking at the first look where you could really begin to utilize PMPM regulation, financing, whatever, will be 2021. And that budget will start to go into, start being put together in really just 12 months right now. And then that only gives you one year after that to hit the federal target on the all payer model deal with the CMM line. All I'm just saying is that I think it's absolutely, you really just don't understand what's going on in the system until you understand what it's costing for a capital insurance. And we have been looking at that, and I can tell you that we believe that we are in line with meeting the goals of the all payer model agreement based on the data that we have as far as the calculations. Other questions or comments from the public? If not, we're going to recess till one o'clock. Again, thank you team. Yes. We're going to resume the meeting that was in recess. And whenever Mike and the team from the title are ready to take it away. Mr. Chair, I apologize. My name is Mike Smith, I'm the interim president and CEO of the title. I apologize at the outset. I contracted a cold that I haven't seen in life. So this is the last time I used the word in my computer. So I may cough during this presentation. I apologize at the outset. To my right, I'll let people introduce themselves. Carol is still the director of operations for Vile. I'm Andrea DeLonguere, director of the client services. I'm Frank Harris, strategic technology advisor for Vile. I'm Bob Cherno, CFO for Vile. So I want to thank you all for the opportunity to support the update on Vile. And sort of, you know, we were here about a year ago and what a difference a year makes. You know, we still have a lot of challenges ahead of us, but where we were, compared to last year, is markedly here for Vile has established a strategic plan. We've developed ways to provide, to make it easier for providers to access the Vile. We have implemented a technology roadmap and the conjunction with the HIC steering committee when you have established connectivity criteria. And also we've sort of stabilized our financial operations as Bob talked about. We finalized the FY20 financial audit in what seemingly was record time. And significantly reduced our budget going forward to the tune of reducing it about a million dollars over the last two fiscal years and we'll use another 500,000 in-state funding in 2020. But there's, I want to spend a little bit of time because we haven't really spent a long time talking about some of the organizational and government changes that have occurred at Vile. And I think that is sort of important just to give you an update of what is going on in those areas as well as I get to my notes here. Like I said, we stabilize operations. We are in the process of re-establishing credibility and our focus in 2019 is to look at the future and talk about sustainability. And we've been having those discussions at the board level as well, at our board level as well as in other forms. One of the things that you'll notice about Vile that's different in the past than it is today, is we really flattened the organizational structure. We've basically taken out the C-suite of our structure. Well, with the exception of the CFO, but we've basically taken out the C-suite of our structure. We've basically taken out the presidential sort of structure and really flattened the organization so that the directors, the ones that you see here and our new director of technology, Christopher Shank, who's in the audience, they're reporting directly to the CFO. And I think that's important for an organization of our size and sort of the nimbleness of an organization to be able to be structured like that. We have new board members that we've added to the board. Susan Versailles, how many of you know? Who was the editor at one time, Mary Beth Eldridge is the representative from Dartmouth. We've never had a representative from Dartmouth on our board, we now do. Tom Ebslin, who was the Chief Technology Officer for the State of Vermont at one point, Lea Fuller from UVM, Kelly Lang from Blue Cross Blue Shield and Vicky Loner from Lemcare. Not only did we want to add new members and new perspective to the board, we also wanted to diversify our board in terms of what we were doing and where we were going. We redesigned our committee structure of the board to include four standing committees, the Executive, the Finance, the Audit and Technology Committee. And we have then started to reach out to other healthcare organizations to see how we can collaborate. One of the things that sort of was the vision back in, you know, it sounds like ancient times now, the 2008, 2007 is how do we bring all these sort of organizations that we've created together in order to collaborate and move forward. And we're starting to do that, and especially with technology and Frank will discuss what I think is a very exciting project as we put it in place and the State HIT plan is in place and is guiding our decision making as we move forward. So a lot has happened in a year and a lot is happening now. And I want to sort of, if there isn't any questions, I'll take questions, but if there isn't any questions, move to the technology update because I kind of find this exciting. I want to bring the board up to speak to what's going on. So as Mike said, I get the pleasure of telling you about an effort that we're really interested in. And it's a joint effort to share components of health information exchange technology. And the participants in the effort, of course, are Diva, the Capital Health Associates, and I think you're probably familiar with that, and there's sort of a contractor role for the blueprint for health and the blueprint for health of participating. One care of Vermont, vital in the capital of Beehive, and Health InfoNet, and Health InfoNet is the main health information exchange. And the focus of the program is on several things. One is on interfacing technology, and that part really involves the interface engine technology that I hope is used for a number of years, rapidly, and in the area of interfacing technology, something called the E-Clinical Works Hub, and I'll talk about that a little bit. Patient-matching technology, master patient index, and you're familiar with that, we're looking to improve patient-patching in the Beehive and in the whole ecosystem, involving all the groups that I talked about. And also terminology services to standardize terminology across healthier data from different sources. Next slide. So what are the objectives? The first one is best-in-class patient-matching, synchronized across the architecture. So really bringing some technology there to make significant improvement in patient-matching that you've heard so much about. Improve terminology services capability and in the area of terminology services, you sort of, it's a long journey with a lot of terminology and a lot of data out there, and so the implementation scope initially will be guided by the state and the accountable care organization priorities. And then improved interfacing capabilities I mentioned, and there's several areas that we're looking to improve there. One is around support for direct web services, and what that means is it allows us to support the version three standard of HL7, which is the biggest standard for healthcare data-facing and healthcare data exchange. It allows us to support that standard directly, which we can't do today. And then gives us a lighter implementation method for implementing interfaces with healthcare organizations. And this is versus what is used today as a virtual private network technology and for small healthcare organizations, it can be difficult to implement virtual private efforts, and so this opens up capability more. And then as I mentioned, something called the E-Clinical Works Hub. E-Clinical Works is an electronic health record that's used by a number of practices around the state. We make the count out to be 33 practices, and in order to be able to receive clinical data from those practices, you've got to have an E-Clinical Works Hub, and so we want to add that capability. And then Capital Health Associates on behalf of the blueprint needs to get a development capability for interfacing. And so we expect as part of the program that we will add that capability. And then finally, we want to put in place with interface technology a method of supporting sensitive data, for example, part two data, to be routed to the places where it's appropriate to route that data, and to do that in a way that's safe and protected and that the customers of the solution, particularly the healthcare organizations sending the data can understand it and trust it and be assured that their data is going to be appropriately protected. So that's an exciting effort for us. And I think the thing to emphasize is that not only is it more efficient from a cost perspective, but the outcome is better. I mean, you can just imagine having multiple patient indexes is kind of an oxymoron. You really want to have the same source of truth for who the patients are. Same thing for terminology. So it's a great step forward for us. I want to mention the future platform study that I spoke with you about in the past. And we're continuing our efforts on this. We've focused more on the shared technology program recently, so sort of slow this effort a little bit and we want to make sure that we understand what we're doing in that program before we make decisions about what our future platform's going to be. And we have released a request for information and we have developed evaluation criteria for exploring that. We considered 35 vendors to receive the request for information and decided on 14 that we thought matched the capabilities we were looking for. Four of those vendors withdrew because they didn't think that they could meet the capabilities that we were looking for and 10 responses were received. And so the team is currently reviewing the responses and scoring those. And the reason that we want to make sure we get out ahead of this with the shared technology program is because our approach is to ensure that the future platform that we choose fits with the shared technology choices. So the MPI, the terminology services and the interfacing all need to work with that platform. And so, and we feel confident that we can make the right choices and ensure that that happens. Any questions on what I just covered? Good, thank you. Oh, I wanted to come back and spend a little bit of time. I've got 10 and a half months before I depart Vile and one of the priorities for me at least what has been, one is data cleanup. Our focus in 2018 and 2019 as you can see with what we've been showing you has been cleaning up data as it comes in through the front door of our databases, of the databases, of the vendor databases that we have as well with an external MPI and also terminology services what we just showed you, shared services. And at a point of origin, which is the connectivity required criteria that we established with the HID steering committee. But it can end there. I think in 2019 there needs to be more focus in cleaning up the data that's already in the existing database. One of the things I think as we look at 2019, we've got some legacy, I wanted to say legacy records but legacy junk in our databases that we really need to clean up. This is mostly data that is accumulated over the years of incomplete records that have insufficient data in them and they're never going to match to another record. So they're called family records. And these records are inflating our unique patient count as we look at our database. And so we asked our vendor HCI or logistic to perform a third party on it of our database which resulted in identifying about 3.1 million records in their database, in that database. However, we strongly believe looking at that number that this record is inflated because of those what are called family records. We've begun the process of cleaning up those family records and we expect that by the end of the year and certainly before I leave, that number is going to be considerably lower than 3.1. So we've had successes in setting the mechanism. We've had successes in de-duping. So we've had successes but we've also had a set back to patient matching that I want to talk about. In June we identified 598,000 new record records at the end of the modicity database and by the end of December, we have reduced that number to 236. However, in February we discovered that our vendor had inadvertently turned off a key matching rule which resulted in wiping out any and more in any progress we had made. We have corrected this and redeployed the matching tool plus we have begun to once again run the tools to reduce the Zulu care records. We expect to be at 189,000 by the end of December. That's a 20% reduction over the 236 that we ended the year with, the previous year with, but we are redoing some of the work that we had already done. We, here's where I think we'll be at the end of the year. I'm pretty sure this is where we'll be at the end of the year. With the data cleanup efforts, the database cleanup efforts that we're doing and getting rid of the phantom records and with the reduction of the Zulu kits to the number of 20s at 189, like I talked about, we're anticipating that our duplicate records will be below 20% of the total unification records. When I look around the country, in terms of the HIEs, that sort of the bogey that everybody's trying to get, we're trying to get to zero and eventually we will bring that number even down further. I can say that because I won't be here as they'll leave somebody else that will be responsible for that, but our goal is to bring that as close to zero as possible, but realistically with an HIE, with all the information coming in from different parts of the state, there will be duplicate records, whether they will be as high as under 20% or lower, we'll see as we move forward. We don't anticipate this having to do this again because we're going to implement the NBI, which will give us a low C into those duplicate records as we move forward and we won't have to rely on a third party vendor in this sense in a third party database in order to have a look C into where we're going and how we're doing it. But I wanted to spend some time because I think database queen up is something that is ongoing, something that I think is important as we move forward is a priority of mine before I leave here next February. So I wanted to give you an update of what we're doing with that area of questions. And Bob, you want to thank you, Mike. I'd like to thank the board for the opportunity to come here and speak to it. To provide an update of Vitals finances, as Mike has said, a lot has gone on in the past year and a lot of good things have happened in terms of Vitals performance financially. And I'm glad to be able to spend some part of this afternoon to discuss that with you. This chart shows Vitals revenue by year for the periods FY17 through FY19, along with our latest results through the end of January, which is the seventh month of our fiscal year. The takeaways here are one, Vile completed in the first half of the year, 100% of its deliverables. And these were associated with, we could call it the stub of the amended FY18 contracts, which ran from July 1st through December 31st. We have now begun work on CY19 that was negotiated in November 2018. That contract is unique for us because it runs from January 1st, 2019 through December 31st, 2019. I'd also like to mention that our FY18 audit was completed in 2018 in December. That, in our last review, had been an open item. It was completed with no material weaknesses or significant findings. Moving on to revenue. Revenue to year-to-date is 58% of the budget. So essentially, we are on budget for our FY19 plan. We believe that we will close out the year with $6 million worth of revenue on budget. During the first half of FY19, our operations team did a fantastic job by completing 61 interfaces and remediated eight more. We still have 44 interfaces left to go to complete FY19. For comparison purposes, last year we completed 101 interfaces for the year. So this year we will be about the same, if not a little bit more, in terms of completion of interfaces. Next slide, please. With regard to vital expenses, the takeaways from this chart are that, one, our current overall expenses are 51% of total FY19 budgeted expenses. So we're slightly below planned for where we thought we would be in this budget year. We expect that the pace of our spending will pick up in the second half of this year as new technology projects get underway and new hires are onward. We expect to be at full head count in terms of our budgeted head count by the end of the year. Speaking of personnel expenses, they make up 54% of our budget. They are the largest portion of our expenses. Currently, our personnel expenses represent 56% of the budget. So they're slightly lower than planned. We expect that our personnel cost by the end of the year will be 5% lower than planned. And that's due to some vacancies in administration and the technology teams. However, the reduced personnel costs are offset by additional costs that vital had to undertake to engage consultants and temporary hires to fill some of those vacancies. We are currently evaluating our material spend and may see cost saving opportunities realized. One example of this is as Mike and Frank spoke about is the partnership amongst vital blueprint and the ACO to work together towards a common MPI improvement project. This should yield savings due to the shared expense of this project. Finally, to close, looking at our balance sheet, it is strong at this point. Our cash on hand is a robust 2.6 million and this equates to over 180 days. For those of you who were around in November of 2016, that number was significantly lower. We expect that our cash flow for the remaining months of FY19 will tighten for two reasons, projected increased spending in our tech projects and also that the revenue from our CY19 contract is lower than it was in FY18 by about $500,000. So those two things in concert will affect our cash flow. We do expect that we will have a positive cash flow at the end of the year but it's important to note that as we go into the new year while we're bringing a balance, we believe, it's important for us to have this surplus cash on hand because it is there to sustain us in this period of reduced funding as we go into 2020. We've been cutting costs throughout this year in order to prepare for this more austere funding environment. So this concludes my presentation regarding our finances. Are there any questions that I can address? You just had a question on both the revenue and expenses for 18, how does that compare to what your forecast was, is there a call, I think you gave it a little bit favorable maybe in total? Yeah, you were favorable. Our revenue was basically on target but our expenses were significantly reduced from what they were budgeted for FY18 and that was due to delays that we had in some technology programs. I just want to expand on that a little bit. We are building cash and the reason we're building cash is 2020 and I think we talked about before that we'll probably have an operating deficit in 2020 and I'll rely on the cash that grows that operating deficit in 2020. In 2021, we hope to have revenue and expenditures of match up in 2020. We just wanted to make sure it gives us some time in order to do that. That's it, Mr. Chair. I mean, we have a lot of other slides in there but we wanted to be cognizant of the time that we were allotted and tried to stay and we're over it by seven minutes, by the way. But we wanted to be cognizant of the time that we stayed through the schedule. So we'll take any questions, there's a lot of slides in the back, sort of performance slides on the various things and take any questions that you may have. Okay, I've got very questions before. Can you go to the Asian providing consent slide and just talk a little bit about, guess where you thought you were going to end the year and the secretary was a little bit behind that? Let me get to that slide. Is this the one? Yes. Yeah, our goal actually is 42%. I think our goal in 2018 was 38% or something. They're about 35%, we were over our goal in 2018, our goal is 42%. There are, we expect to be at the 42% level. This may show it a little behind but there are several encouraging things that I just wanted to bring to the board's attention on this, anticipating this question that I would be asked on this. We have gone live since the last time. As you remember, we had the University of Vermont Medical Center which contributed a lot to bring it up from 19 to the 38, 99% we have now. The Southwest Vermont Medical Center has come on live with electronic consent, electronic consent projects in the progress after EHR upgrades will be North Eastern, on North Country, Northwestern, UVM Health Network, the central Vermont and then Porter. Well, we have found that with and through EHR right now, it's sort of not capable of providing the electronic consent, private world, with Mel Nascati and Grace Cottage and we're still investigating sort of the technical aspect of Topley Hospital and Gifford and on hold right now is Springfield and Rutland Regional because they have the Rutland Regional, Springfield because we've read about it and Rutland Regional because of competing priorities. So we're starting to bring into that. I think you'll see us get the goal of 42% this year. Can you ever accomplish the goals that have been envisioned for vital with a less than a 50% threshold? Is it even possible under the current consent policy to become a success? Yeah, that's, in my opinion, no. That's going to be a challenge. I think the question that I would say is do you want to be fully operational in an efficient and effective manner? And I always want to be operational in an effective and efficient manner. And an off-out consent allows us to do that. If you want to continue to have sort of a drag on your ability to be as efficient as possible. And let me just explain why this is so important. When you're a provider, you don't have a lot of time. And we found that the consent policy isn't working, hasn't worked since we've implemented it back in the 2000s. But when you're a provider, you don't have a lot of time. When you go in to check the patient's record, either through within your own EHR, as we are more apt to do as we go on to these cross-community access, like at UVM that just went blind. But if you go in there, you're expecting to see your patient. If you go in there and six times out of 10, you can't see your patient. That sort of bounces it out of the workflow. And so it's not an effective way to sort of incorporate into the workflow. I would say this. I didn't hear a mirror, so I guess I'm an expert. But we have a very good... Vital is very good at doing what it does. And we're comparable to some of the death-run HIVs that are out there, whether it's Maine technology, we have the same technology, whether it's Delaware, we sort of have the same workflows, Delaware, whether it's Colorado. What we don't have, that some of those other states have, is a consent policy that allows us to be fully operational. And I'm convinced that's because we aren't in the workflow as efficiently as we should be within the ethical provider network, whether it's a hospital or whether it's a practice. So if you're asking me, do I believe that consent is needed in the state in order to fully operationalize the HIV? Absolutely. Who loses when a doctor can't access the patient's records? Well, in my mind, there's two losers. I mean, the provider loses because they don't get a full record of what the individual may or may not have. But number two, I think the patient loses because they kind of expect a doctor to have the information in front of them. Now, we can talk about, and I think this is important, if we're gonna move to an opt-out in the state, which I believe fully, I believe that in 2006, I believe that now, if we're gonna move to an opt-out, I do think there's an implementation period that we sort of have to bring people up to speed. We just can't, and we've gotta have that collaborative process as we move forward. But I think it's important that we tackle this issue sooner rather than later in order to, you've got all the elements of a working of a very efficient HIE. You've got the HIE Steering Committee now. You've got the plan. You've got vital that's on its way. There's one component that we're just lagging behind and that's the case. Other questions before we talk. Is there any relationship of remote patients providing to set that statistic and the diminishment of the duplicate records? I.e. if you diminish, continue on your path of reducing duplicate records, does that have an effect on your recent patient providing to set? It could, but we didn't see that much of a fluctuation, maybe because our vendor was adding duplicates as we were reducing them, but we didn't see that much of a fluctuation. It could, in that regard, and we make that number harder to get, yeah, you could see that. I'm not expecting a huge amount of change, but you could see that. Do you have any other questions for the board? If not, we'll open it up to the public for comment or questions. Eric. My name is Eric Schultes with Office of Health for their Advocate. So I just wanted to follow up on the question you asked, Chair McMullan, about who loses when you can't see the records. Who loses when there are multiple, when there are duplicates in the system? So like even if you could access it and you have a 20% duplicate rate, how trustworthy can the patients and providers feel that they're getting the accurate information that they need? That's a good question. That's why I think we have focused on the data cleanup and the reduction of the duplicates as you move forward. From the challenge with duplicate records is that we don't see the patient, we just get the information that's coming in so we can't query what the patient is who are putting things in place to reduce it. Who loses is it wastes the time of the provider. That's who loses. And we're recognizing that as a loss for the provider because he's gotta wait through those. He or she has to wait through those to make sure that the duplicates are there. You know, I think we are on the process now of doing things that other people aren't doing. They're looking, we're looking very, very extensively at our data and making sure that it's clean. There's a lot of databases out there that aren't doing the same thing. But to answer your question specifically, I think the provider loses because, and in the end the patient loses because if they're duplicate, first of all, six times out of 10, they're not gonna be able to see whether there's duplicates. But the second of all, I think if they can see it and there are duplicates in there, it's the provider takes more time to go through that. And secondly, you know, they may become discouraged and we've just gotta clean that up. Any other questions or comments from the public? Yes. I was my primary care provider yesterday and I don't know if they're hooked into vital or not or however, but I was, made a reference to what happened to me 12 years ago and they were on the computer and on the data and they couldn't find it. Scrolled through, they couldn't find it. So I had to explain what, you know, explain it all. So I don't know if that's part of this, but it was an interesting thing because, you know, the computer backed up, locked up and then we had to reboot the thing and on and on like that took about a half an hour before she couldn't find it. So I don't know if that, it was up in the LaMoyle County area, so I don't know if you deal with that or not. But let's talk afterwards, let's find out who the girl is. I know who the girl is. You have to answer them. Yeah. Other questions or comments from the public? Dale. Follow up to his, in general. How long do you hang on to patients that connect to patient records? Is there a law around how long the data must be held somewhere around 10 years or is that correct? Well, I don't know that had not gotten rid of any data that we had that accumulated and that's, that it causes two problems. Some of that data in areas of one field was sort of situations. The second of all, I may come to the board at some point and talk about reducing the number of years that we have for records. We have to have an engagement with the provider community and to some extent the patient community on what that's gonna look like. But right now we've got a lot of data on a lot of our monitors, but that isn't accessible to their providers. That gets into an issue that I'm familiar with too, which is in the old days you may have file folders because you didn't have computer systems and if you were a child growing up with healthcare issues, but you can get to the age of 18, you had two or three files, which was as much as some people would have their whole life. That issue existed even then. What did you do? How long did you hang on to the data? What was relevant from birth as far as healthcare information that must always stay with a person throughout their entire life? It is extremely frustrating, because I now have had this happen, where I will walk in and it looks like I'm no more than eight years old. When I asked them, what about these significant healthcare events that occurred in my life? Where did they go? While in their records, not only did they not exist, I don't exist. It gets a little strange that way as far as you're sitting there, you're 58 years old and there's nothing that shows you grew up, there's nothing that shows anything beyond eight years. That I think will be a problem going forward. I don't know how everybody deals with that. You can end up with those questions where it's like how many surgeries have you had in your life? If you list six, they might only have records for two. And what kind of medical errors, what kind of bad judgements can come out of issues like that? I think this will become a very important issue for a certain percent of the population. Do you want to tackle that at all? Well, we strive for as a complete medical record. I mean, that's what we strive for is the complete medical record. Just sort of go back and answer your question. HIPAA requires just eight to seven years. We haven't gotten rid of any data, but at some point, I can't come back to the board and talk about that issue before I leave. So, on an individual basis, I can't speak to the individual aspect of it because of the privacy concerns in the door to my door. But on a global basis, we're looking for the doctor or the provider to have a complete medical record that is up to date so that they can look at it and find out what are the pertinent aspects of that complete medical record. That's our goal. Any other questions or comments from the public? If not, thank you very much. Thank you. Sorry for all the talk, we're out of paper, zero. I publicly thank Michael Costa for his years of service in the state of Atlanta. Not only have you done an outstanding job in your current role, but I think back when you were staffing the Bluebird and Commission on Taxes and things like that, you have a career that demonstrates what's possible in government. Thank you, Michael. We're going to issue in your current role, but we're also going to welcome you in your new role. Well, thank you very much, Mr. Chairman. Michael Costa from Diva, so grateful for your kind words. I've had, it's been such a pleasure to serve in the state government for the last nine years in Vermont. Although I have less hair, I have more appreciation for everybody. We should still have that work. And I think the one theme that runs right for all that work is I just really like typical problems. I'm grateful for the lots of players for who will help you with those problems. And so I'm grateful to be attacking healthcare from a different angle. Northern County is not here at St. John's. And I have this strange feeling that HIE will be part of that discussion, too, as they learn more about how a practitioner's do their work every day. Today, we're offering more of them here at LA Richards, our HIE lead, just sort of a run-in-the-mill update. And I think that's really important. We spent a lot of 2017 and 2018 trying to get this program out of the dimension, back on track, and had to ask ourselves questions like, what does it mean for the HIE program to be back on track? What does success look like? How do we go from putting, answering, kind of hot legislative questions to having standard work that we do? And so I'm really grateful to be sitting here with Emily after the work that she and her team and Mike and his team at Vital and the HIE steering committee has done over the past couple of years to get to a place where we have standard work that we do. And so I'm going to hand it over to Emily in a minute and I'll walk through our update and then we're happy to answer what the question is that the board has. Last time we were here in October, we provided a program update and that was followed by a presentation of the HIE plan in November. I was going to talk about a couple of highlights that have happened since we were here last. So the first is just to highlight that we've got Vital met all of the requirements back when we set them up for the 18th reported on our progress for that end a number of times last year. And then the final reports for requirements were submitted in January. That was a report on the consent which you noted they presented to you as well as a report on the interoperability of systems which is the topic that we covered in great detail in the health information exchange plan. So that's all then completed. We have convened the 2019 health information exchange during the week and as you remember, this is a group of people that's behind the health information exchange state-wide plan. So the new governance models outlawed in that plan and we're really grateful to folks who have joined us again and to new members. As I mentioned, our 2018 contracts are underway so I thought I would touch on a couple of highlights about the framers and Mike and Frank did a great job of highlighting some partnership work that's happening to develop sort of foundational HIV infrastructure in the landscape. That's really in the planning phases now but we're pretty confident that we can get to a place that more efficiently uses resources and maximizes the sort of benefit of the technical output that we're also getting here. And finally, we thought we'd touch on a couple of things that we're keeping in mind and a little changes that are coming down as well as changes in federal funding. So just to stop on the slide for a moment, I am so pleased with, in a way, how boring this slide is because we just wanted to be competent and we wanted to be boring. That said, there's a lot here and I think there's a lot of listening from the legislature and this board of policymakers that say, hey, stop telling us about HIV, show us what you can do. And so to meet all the act 2087 requirements isn't going to be a deal for us. The steering committee was basically this board and others saying, if you're not around this program, you have to listen to what people want. I think that's still a work in progress but we're trying really hard to listen to what folks in the healthcare ecosystem want of HIV. So I'm pleased that that's continuing. With my little contracts, I was so pleased that one of my little slides said that they had 100% of their rules, as you know, they transitioned from grant to a little space contract. There's no guarantee that that's going to be successful so we're really grateful to buy all in the team to hit all their marks on that. And then I think one concern from this board and from the legislature is that we're at risk of being working in silos and buying the same thing three or four times. And so the fact that we're pursuing shared infrastructure to make the team and interview in more detail is a really big deal. My contribution to that was quite modest. It was to bring everybody to the same room and say, maybe you have a checkbook and we're not going to pay twice. There has got to be some sort of way for really smart people to figure out how to share resources in the way that was originally envisioned in the creation of the my health information exchange. And so I'm grateful that there's a whole bunch of people doing hard work in taking risks to try to bring that to reality. And then, you know, Corey, a commissioner industrialist that likes to say that he's like the mayor of Athens and I'm the deputy mayor a lot of people ask me how to stand in the fence or like Zeus, you know. And so I do think it's important to keep our eye on what they're doing because they really just based on their financial commitments play a nice role in how and when we develop a health information exchange in technology. Once we have the 2019 work on the health information exchange theory committee, this is the committee goals here that are straight from the health information exchange plan. But there's a couple that we should focus on. Predominantly, their goal to draft a technical roadmap that reflects the three to five year IT investment strategy. And this is really a central a way to build off of the work that was done last year in the strategic plan as we targeted the mystification of health information exchange and really setting statewide goals. So this year, the steering committee's going to come together and say, we're going to define what we want, what we're trying to achieve. Let's define how we're going to get there. So this is a deeper dive, one level further down to think about how we're really investing in technology to get to share goals. And so that's the requirement for us to really understand how we find this and ultimately how we make this sort of ecosystem sustainable and what the state's role in that sustainability is. So yesterday we awarded a contract to a partnership group at Resolvency, Lantana Consulting, one of their CEO helped us a bit last year with technical aspects of the HIG plan. And her company has partnered with Vellatora, which is an offshoot of the Michigan Health Information Network. And if you remember, perhaps going back to Don Gallagher's presentation from her 2017 evaluation, Michigan's really held up as one of the national models, not just in how they do technology, but really how they plan and new governance. They're the sort of the originator of what they call the use case factory, which was a concept that we took here in Vermont and said, okay, so let's base our strategic planning on use cases there, how we use health information exchange. So we're really excited about this partnership. They should get started in the next few weeks and they'll be guiding this here and committing through that development of the robot and potentially other work related to their experiences. So we'll be back here November 1st with an update to the health information exchange plan. It will include what we will accomplish in terms of that tactical plan at the end. It says, you know, sort of whose role, where in the foundational exchange services and end user services that role lands, what could be there to accomplish for the year, and then how we want to build on it in 2020, as well as the update with the technical development. And I'm a bit of a viewer. I mean, I think it's easy to get excited about technological innovation in the HIE, so it really has a great team. And they'll say, hey, Michael, we really want to talk to you about blockchain. And I'm sitting there going, hey, we're still trying to put the building blocks together of what do we want, why do we want it, how do we evaluate what to invest in, given scarce public resources and the fact that we have a very definite healthcare reform direction, and then, okay, well, it's our three to five year roadmap to build it, and we'll, so we know what we're doing and what we're doing, and we'll be contesting our own competency and trying to bring some of these programs and projects to life. And so, you know, it's just one of those things in health information and exchange and technology where it's brave to move your feet. You know, if you think in big thoughts, they keep moving towards really incremental progress in building capacity and competency and what we do. Any questions? So, the vital contract for this year, I think probably just the most important thing to point out here is that we now have a strategic plan that aligns with what we're asking of our biggest vendor and the operator of the health information exchange. So if you look at the top right here, that is the IT services model that we have in the health information exchange plan. And it's just meant to show that, you know, there's sort of baseline services, foundational services in health information exchange like security or identity management which exchange services that are sometimes offered by multiple vendors. That's where you think of pulling the data together, making sure it's of high quality and making sure it's accessible. And then on the top of that, you can only know those services once the foundation will make exchange services that are in place. This is sort of the more exciting things, consumer tools, fordals, analytic tools, factual use of the data. So all of the items that the state is asking of vital this year are in direct alignment with that services model. So you see here, we've got the contract split into sort of two pieces, being it's in operations of the health information exchange system itself and then systems development and enhancements. And I think Mike and Frank went over our operational goals for this year to continue to automate the consent process so it's easier to transmit consent preferences and thereby increasing the consent rate. And our goal for this year is 42%, last year was 35% in this, I don't know if they exceeded that goal for the last year. Yeah, I would say that you look at those foundational services and consent in one of them, the slide that Vital had up on the screen was get a goal 35, we've exceeded that goal, we're now pushing towards a goal 42. Our understanding of the national landscape is that in states that have opt-out consent for numbers that we're talking about are 92, 93, 95. And so it's really about how solid a foundation you wanna build. I'm very respectful of the fact that people can disagree on the merits of the policy, but we really do look at it as a foundational piece of the program and it's hard to imagine driving to the proper level of success in those other aspects of that diagram if you do not have a consent policy in place that might get you to scale. There, Vermont is one of a handful of states that has opt-in consent and most states have opt-out. And it's our understanding that two out of the three states, the other two from Vermont, Rhode Island and Nevada, or are actively considering changing their consent policy. So we'll be respectful of the fact that folks wanna have more conversation about it that's understandable. We wanna do it right, not just fast, but there's a pretty stark, as we've said before, before this board, there's a, Vermont is significantly out of step policy-wide as to do you think there's a big programmatic impact to that policy choice. Another operational goal for the year is to continue to reduce duplicate records, but I think we're going to be on my foot into that in greater detail. So when we think about developing the system, although not on what we already have, there's a couple of areas. And you know, we call these systems development in part because of how they're funded. Anything that falls under systems development is funded by the federal government at a 90-10 rate. So they're partnering with us to continue to enhance our health information exchange. So a couple of highlights here, data access. I think, you know, Vitals always work to make the data accessible through their provider portal and now they're really thinking about how to make data accessible in the electronic health record. So if you just put yourself in a provider shoes, do you wanna have an extra login? Do you wanna go to another system? Or do you wanna just look at the electronic health record that you're using with your patient at the time? And they really prioritize making data accessible in a way that's gonna be useful to providers. On data aggregation, you know, the connectivity criteria was part of our health information exchange plan. It sets some standards for the quality and the volume and the accessibility of the data coming from electronic health systems to that exchange and aggregation center. And so the way that that connectivity criteria has developed in the last couple of years is really admirable. And Vitals committed to developing work plans with each healthcare organization that they're gonna work with this year to get them on a track to continue to develop towards higher and higher tiers of connectivity criteria, which just in terms of our public role, I think is a really great way to sort of get the outcomes that we want the most accessible and highest quality of data in the exchange server. And then on data quality, we will be compensating vital for the project that they detailed a portion of it related to translating data for use, it's called terminology services, and making sure that the records are where they should be. So that's part of their partnership work, but you know, we're confident that they are, they've committed to sort of the foundational aspects of shared infrastructure that are gonna really make a difference in quality and usefulness of the data. I'll look at, just a quick look at sort of national level changes that we're keeping in mind as we think about some day-to-day H&E operations and planning with the scary committee. The first is one that we talked about before, the High Tech Act originated in 2009, and that's really why, what incentivized the purchase of new civil electronic healthcare systems across many aspects of our care system, and then ballooned, and that's the federal funding that we use today for things like the health information exchange that funding expires in 2021. And what CMS, the Center for Medicare and Medicaid Services has said is, we know that this work, you know, there's still a lot of work to do and after we issue one, we still wanna be a part of it. So they're trying to create an avenue where funding is available for Medicaid enterprise services. You guys might know, we have an NMIS for clean system that sort of is the back end of Medicaid. So this is going to impact our federal share. It is also going to impact the types of projects that we want to do, because they have a couple of years ahead of them, there's not formal guidance out yet, but CMS is certainly making a lot of changes to adjust for this at this point, and we'll have to change accordingly. The CMS and Office of the National Coordinator, the ONC, have also come out with some rules for the grant interoperability or that exchange of data across systems and patient access to data. They're just in the proposed rulemaking phase, but these will have a pretty significant impact on payers, on the sharing of data standards for what allows for exchange across systems and potentially how Medicaid and Medicare patients can access their own data. So we'll keep a close eye on this one. I think the comments and the rules do in early May, so probably a couple of months after that, we'll have more come on. And this deltails with the 21st Century Care Act, the Trusted Exchange Framework, or TECCA. This has been a topic I was highly talked about over the last couple of years. It's a mandate of the Office of the National Coordinator to kind of think about how nationwide exchange happens, and some of the new proposed rules will enforce this, and potentially the federal government will come out with more formalized guidance on how we'll change TECCA, which will force us to think a lot about the role of the health information exchange here in Vermont and how that interacts with the issue by default. Just to go back to the first piece of it, I think one of the things for this board to consider, or just be aware of, if you were running Medicaid, or Medicaid administrator, you're constantly wearing two hats. One is the hat of Medicaid the payer, just like in cross-bushier, or MDP, or Medicare. We roll people in, we roll providers, we pay people in medical services. But we also have on the hat of being responsible to some extent for the healthcare system. And that's where we do HIE work in the service of providers. There is an internal challenge in bringing together those two streams of work, because right now, HIE work is not that well connected to MMIS. And so I did one challenge that my successor will have in Medicaid is making sure that one thing does not swallow the other thing, that we maintain a proper focus. I think we're building in service of providers as opposed to things we're building in service of our whole payer. And it's just gonna be important to lose any momentum in this work as the federal funding experience changed. So that's a bad, nice and the news, programmatic moment. So that's our responsibility, but one that you should be aware of. And in TEPCA, we have to keep being mindful of federal changes in policy and posture, as I do think our informal conversations with the federal government generally go like this, hey, we expect to see some level of connection between the states and across the nation. We don't wanna pay for 50 plus silos of healthcare information, it's not. I don't think I'm gonna be disagree with that, but how you do it really matters. And so we have to be running forward whenever it comes at us from the federal level as they try to encourage data and connection to be more portable and transferable across the states. Those are all, yes, those are all of the questions. Here are your questions from the board. I just wanted to join Kevin in plotting the work that you've done, Michael. You and I have not crossed paths in person very often, but I remember reading about the Blue Ribbon Tax Commission which is an area I knew something about and seeing that Kathy Hoyt and Bill Sear were gonna be part of the team and I thought, well, this is gonna be very interesting to watch. And when the report came out, I just found it to be really well done. And I applaud you for that. And then as I kind of joined this arena, I found that there's just a lot of integrity in your work and I just want to applaud you for that because Vermont is lucky to have had you and we are lucky not to lose you. And thankfully we'll be seeing you from another direction. I do have a question just about continuity. We talked in the past about the Steering Committee, the whole issue of continuity and the beginning and the end was important. And do you have any insights that you can offer us as to how your role in that might be replaced or restructured? So first of all, thank you for your role wishes. It is easy to look smart when you have people like Emily Richards and Alicia Cooper and there's a few people working to sell hard. And so I think that the program model is going to be a lot of continuity. And certainly you don't want to get in front of the commissioner about your Senate governor's office. And do you think that the number one thing we're all talking about in my successor is continuity? We focus on how to restructure my job roles to make sure they're manageable for folks. And then we focus pretty heavily on internal candidates who will be able to keep the ground running because we don't want the momentum on payment delivery system reform, particularly when you view H&E as a form of delivery system reform to lose any momentum because of the change in the leadership. So I think I would urge you to stay tuned. I think we'll come, don't bother you guys on this soon, but it will hopefully be well calibrated to maintain momentum. I mean, AJ is certainly going to be specifically about a cross payment delivery system reform version of it. That will open it up to the public for any questions or comments? Dale, I think this fits, but it's going to seem a little bit like it doesn't fit. It's a broader issue that I was tuned into through somebody that works in genetics and hence the issue I'm about to bring up. With all these data projects and the collection of the data, as previously noted in the last presentation and was mentioned in this one, often versus opt out is part of what makes this all work because they need that. But when you collect data like that, a door opens to something that we may or may not consider and that is eugenics practice through data. And it's very troubling and Vermont has the history of having done that. I don't believe they would want to do it again, but it is highly probable that with this kind of data, if they're going to have opt in so that all these things work the way they want them to work, how do we control what they do with the data so it doesn't get misused and eugenics brought home to me just how important an issue this is. It's like, wow, there's a lot of room for real damage. I hope that we've learned the past history and we don't repeat the mistakes in the past. Also, if you're truly concerned about that, I don't want to use the term paranoid, but if you truly feel that way, you still would have the ability to opt out if the policy wouldn't change. But I don't know, Michael, do you want to address that question? I would just say briefly that I just wouldn't want to mix up the issues of the manner in which consent is given opt in and opt out with permissible uses of the data which are governed by federal and state law. I'm not trying to diminish your concerns in any way just to say that to me those are really separate issues and there's nothing about the consent policy that's being contemplated right now that would change state or federal law about permissible uses of the data. I defer to the general counsel of the board for the specifics around HIPAA and state law, but I think it's a really important distinction to make down when we're talking about the consent policy. I apologize. I don't mean to occupy all the time. I neglected to pile on with the thanks for Michael Costas' job. I didn't know Michael before I came to this position. I have known him to be cool, calm, and collected no matter what the situation is, for those who have worked with me, just like I am most of the time. The one thing that I like about Michael is his intellect at looking at issues, even in an adversarial position, the ability to sort of think through the various issues and it will be a loss for state government, but it will be a gain for the health care system and I really appreciate the time that I got to spend with Michael. I would just note for the record that my initial reaction I used was some of us tempered. Thank you. I'm happy to comment on this often. I like it. I'm not sure we should do that. It is after all televised. Thank you. As you all know, I'm just going to St. John'sburg. I won't be far. I'm really excited to continue on the health care reform journey. I'm leading the UF really good on the team that we have. You just don't get anywhere in this business without a good team. So I think I'm really excited for folks to be able to step up and keep that momentum going and partnership with the board and others. Kim Lee, I guess we'll be seeing you again. Melissa and Ren are coming up. Can I just give it a second? Absolutely. Good afternoon, Mr. Chair and board members. For the record, my name is Lynn Combs. I am the associate general counsel of the Green Mountain Care Board. I know I've met everybody sitting at the table, but there are some within the audience, so I have not met them. I'm also joining, I should say, by Melissa Miles, who's the health policy director at the Green Mountain Care Board, and I will definitely see the subject matter expert on these types of questions and conversations. We just wanted to sort of review with everyone where we're at on an issue that we discussed at the board meeting two weeks ago. We received a request from One Care Vermont to amend the 2018 budget order that we issued two weeks ago at our board meeting on February 27th. The temporary is from One Care, so I don't know your position, presented to us on the budget amendment, and we just wanted to reorient everybody to where we left off. First, I think it's worth naming the two specific areas where One Care has requested an amendment. Bear with me while I read through these, but there are two specific orders that we issued in the end of 2017 that we've been talking about. The first one is order F4, and that is that One Care must implement the delegated risk model described in its budget proposal except that it must establish reserves of $1.1 million by July 1st of 2018 and $2.2 million by December 31st of 2018. One Care has requested that we amend that order to say and order them to establish reserves of $1.4 million by December 31st of 2018 instead of the initial $2.2 million that we ordered. The second request that we have is with respect to order H that we issued, One Care must fund its other population health management and pain reform programs at no less than 3.1% of its overall budget. The board will monitor this ratio through the year to ensure it does not decrease below 3.1%. If the percentage decreases, One Care must promptly alert the board. The amendment request that we have from One Care is that we lower that 3.1% number to no less than 2.5% of One Care's budget to be spent on population health reform and pain reform programs. In its presentation two weeks ago, One Care did present the more detailed rationale for why they already came these requests and the reasons that we are or where we are at the close of 2018 and beginning of 2019. After following that meeting, the board opened a public hearing which ran from February 27th through March 6th. During that comment period, the board received two public comments. One from the Office of the Health Care Advocate and then a response from One Care Vermont to the comments from the Health Care Advocate. I will just also note that packets of our information, our slides, and also both of the written public comments are available outside. They are stable together as one packet and all of this information is also posted on our website under the meeting materials section. So if anyone has any questions or want to look at this in more detail. That being said, I'm going to do my best to summarize the information that was stated in the public comments and apologies ahead of time if I miss anything. The Health Care Advocates comments, the general focus was that the requested change that One Care has asked for in actuality reduces One Care's public health management investments by $3.7 million. The Health Care Advocate noted that Vermont, the Vermonters do have a significant need for the public health management investments. In their comment was that 2018 spending should not be set aside due to implementation delays, which was one of the things that One Care talked about in its presentation. And the request from the Health Care Advocate was that all unspent money should be used to increase One Care's population health budget for the coming fiscal year. One Care Vermont's response to that public comment, the highlight service follows, One Care agrees that the investment in public health and prevention initiatives is very important. Not including the value-based initiative fund, which was not included in what One Care's, or value-based incentive fund, sorry, value-based incentive fund spending that One Care has not included in its presentation. They did spend more than $21 million in population health programs in 2018. One Care does not have any additional unspent funds on their books or sitting within their bank accounts. And any increase in spending for 2019 that might be contemplated beyond what is in the already approved 2019 budget would require additional revenue to be collected from hospitals who are in large part funding all of the spending that is going on in population health management issues. So that's basically where we're at, I think at this point. We're happy to answer any questions board members of the public might have to the extent we can. We also have representatives from One Care here who are going to volunteer them to answer questions that people may have. So I think I'll turn it back to you. I guess the logical question is to One Care, since they have someone there, if they feel that their ability for success in the future has been adversely affected by the inability to make these population health adjustments. So this is Tom. We're starting to find through One Care. I don't think so at all. I think in fact we have a very successful 2018 operation for timing of program rollout, changes to attribution, et cetera, especially the primary care pilot, for example. The ratio that we have achieved is less than what the budget order required. But I believe that it was a very successful year and that we rolled out all the programs for tremendous growth period and are continuing to evolve and grow as we get started in 2019. So I do not see the results of 2018 in any way as a detriment to 2019 in the future performance of the ACM. Other questions from the board? Any other questions or comments from the public? Seeing none. Is there anyone who would like to make a potential motion? I can do it if you'd like. Would you prefer one or two motions? I would. I'd be cleaner to do two. Okay. Then I will start with moving to approve the requested amendment to order at four by reducing the reserve requirement to 1.4 million by December 31st. Is there any discussion? I had a comment on it that I would say in terms of my thinking about this is I think when we approved the budget there were a number of unknowns that we talked about two weeks ago when we were here in terms of what the Medicare program would require in terms of backstops as well as the reinsurance-like protection that one here ultimately got. So I think that combined with seeing how the risk model has rolled out for me makes me comfortable that this reduction makes sense and doesn't pose a potential risk to the program. Also I think when it comes to reserves we have to be careful about it both ways. We want to make sure there's enough reserves but we also don't want to owe the reserve because I think that then may not be the best investment of the dollars. So that's my comment. Is there a second to the motion? I'm sorry. Okay. Other discussion. If not all those in favor signify by saying I, I, any opposed? Okay. Remember lunch. Okay. I'll move that we amend order H to adjust the percentage of spending from 3.1% to 2.5% on the population health reform and payment reform program. Is there a second? Second. So moved and seconded. Is there a discussion? Again, I'm happy to comment on my thinking on this one. I think when we did this part of the order the other thing we should all remember is that we also separately included in the order that seven and a half million dollars be spent on the blueprint for health and SASH and we did it in that two-part way because we wanted to ensure that that money that was cranked in the negotiation and tended to go to the blueprint and SASH programs did that so I just wanted to point out that that amount is not reflected in the ratio. I think I certainly am very concerned about the proportion of spending that goes into the population health investments that is a very important and innovative part of this model and I think is necessary for us to really keep an eye on. However, this was the first year. We have to expect that there will be operational issues and rolling out a number of programs obviously can create those operational issues so given that it's the early years this is the first time that we try to do this kind of proportional order as well as kind of a ramp up period that it's those components that make me comfortable with. Any other discussion? I just might add to that I'm fully agree with what Robin said this was the first year and it was the growth year as it's 19 and I haven't heard a complaint from any of the potential recipients of this additional funds in 2018 complaining that they didn't get their funds rise for example was one that didn't receive its full allotment but it seems to me from what I've heard is that vice president received its full allotment and so after the fiscal year came this amount had not been necessary to fill in the hospitals and we moved on into 2019 so it just seems like a simple administrative clean up here and that's why I support it. Other discussion? If not, all those in favor signify by saying aye. Any opposed? Thank you. Thank you very much. Any old business to come before the board? Seeing none, is there any new business to come before the board? Seeing none, is there a motion to adjourn? It's been moved by member Holm, seconded by member Yousper to adjourn. All those in favor signify by saying aye. Aye. Any opposed? Thank you everyone.