 All right, well, it's one o'clock. So I'll call to order the Green Mountain Care Board's meeting of February 14th, 2024. We have two presentations today, one on the cost share reduction policy update, which is a particularly sweet topic for Valentine's Day. And then we also have the vital Vermont information technology leaders quarterly update. And before we turn to those, we'll have the executive director's report. Thank you, chair Foster and happy Valentine's Day, everyone. So I wanted to report out that on Monday of this week. We had a really terrific general advisory committee meeting. We heard from our contractors who are working on Act 167 community engagement work. And I just want to send a shout out to the advisory members who were really helpful. In providing input to that process and their feedback was really appreciated. That meeting is on our YouTube channel. If folks want to take a look at that at some point. I also just wanted to remind you about two open public comment periods. One is related to the community engagement work for Act 167 still taking any comments from the public on that. And the second is that the continuing open public comment period for a next potential all payer model. AHS and the administration are leading the negotiations on any next bottle. And any of our comments we shared directly with them. And I guess the last thing I'd say is over the next couple of weeks, our schedule is pretty heavy and we have, I think it's next Wednesday. We start earlier in the day. So if board members and of course the public can just take a look at our schedule, be aware that we may be having a meeting in the morning and the afternoon and several days coming with that. I would turn it back to you, chair Foster. Great. And we have minutes from February 7th, 2024. Is there a motion to approve the minutes? Call of approval. Second. All those in favor say aye. Aye. Aye. Aye. And the minutes are approved. And I'll turn to Mike Barber, the general counsel of the Green Mountain Care Board. And Mike, I'll let you introduce our actuaries and provide the presentation on the cost share reduction update. Great. Thank you. Well, we're here today to talk about a potential modification of the guidance that the board adopted last year around calculating cost share reduction and silver loads. And we have Jackie Lee and Kevin Ruggerberg. And I think Jason Doherty from Lewis and Ellis, who are going to go through a presentation. And then the plan is to come back on the 21st of February for a vote. So we'll come back, update you on any public comments we received on this, and then looking to get your vote on that date. So I'll turn it over to someone from that will need to run us through the slides. Aye. This is Kevin Ruggerberg. I'm going to get the slides on the screen. If somebody could let me know when they're visible. They are. Okay. Can you see them? Anybody? Okay. Yes. As Mike said, we're discussing the CSR loads for contract year 2025. Premiums on the individual market. I want to start by providing a little bit of historical context. So the ACA requires health insurers to offer reduced cost sharing on silver plans for low income individuals. But in 2019, the federal government stopped funding those additional benefits. So silver plans are required to offer benefits that are richer than a basic silver plan. And the only funding mechanism available to cover that is an increase on silver premiums, and that's known as a CSR load in Vermont from 2019 through 2023. Carriers were able to set those loads themselves according to their own methodologies. The board did introduce guidance constraining those methodologies somewhat in 2024. This slide shows the loads themselves by carrier and by year. I will note there's some averaging going on because it has varied by plan some in in the past, but broadly what we see is there were no CSR loads in 2018 because the federal government was funding those benefits directly. They then were introduced in 2019, but we saw sort of a gradual decline in CSR loads from 2019 to 2023. The 2024 guidance did cause an increase again in those CSR loads. And we sent some proposed guidance, I believe at the end of last year, to stakeholders for comment for 2025 that would have caused a modest increase to these CSR loads to about 25 percent. We're now also discussing a revised proposal for the 2025 guidance that would cause a much larger increase as I'll discuss further on. Hey Kevin, I'm not seeing your slide smooth. Oh really? You're not seeing there? I mean, I did it, but I'm doing it on teams. That's okay. I'm having the same challenge. I was moving them through by myself. Okay. Oh, we're moving them ourselves. Oh, I apologize. I see now teams is trying to do it. Ah, I will do it through teams now. Thank you. Okay, so just to make sure it's clear what the significance of the CSR load is because everything I've said so far is fairly dry. The higher that silver premiums are because silver premiums are the basis for federal APTC tax credits. For every dollar that silver premiums go up, there's an additional dollar of subsidy available to any members who are subsidy eligible on any plan that they purchase. So as you increase silver plans, effectively all of the other plans get cheaper. And that increased affordability on the other plans is actually by two separate mechanisms. So if we look at this first section, who's helped by increased silver loads? One is anybody who receives APTC, anybody who receives those federal premium subsidies, is receiving an increased subsidy if the silver load goes up because silver premiums dictate the subsidy. That is, I think I can comfortably say a majority of this market already. And then also anyone who isn't eligible for APTC still sees a slightly lower premium from higher silver loads because the gross premium, the unsubsidized premium for their plan goes down slightly. The silver load is basically a ratio between the on-exchange silver and everything else. And as that ratio gets bigger, the average doesn't change. So as the silver goes up, everything else goes down. As a consequence, even if you're not getting any subsidies, if you want to buy a bronze plan or a gold plan or a platinum plan, it gets cheaper as CSR loads go up. Now, there are some people who are nominally hurt by increased silver loads, but is a fairly small population and it's described in that next section. To be hurt by silver loads, increased silver loads, you really have to be both ineligible for premium subsidies and enrolled in an on-exchange silver plan. So this is people within Vermont. That means a family with an income of $375,000 or more, or an individual with an income of $135,000 or more. That basically comes from the fact that you're eligible for subsidies right now if the silver premium is greater than or equal to eight and a half percent of your income. So given silver premiums are in excess of $30,000 for families, it takes a fairly high income not to be eligible for subsidies. So only families above these thresholds who choose an on-exchange silver plan are really hurt by this sort of change. Obviously, it would be preferable that they not choose those on-exchange silver plans because as long as they choose anything else, they move into that helped bucket. If they choose a gold or a bronze, now they gain the benefit of the increased silver load because those plans became cheaper as a consequence. There's also a substantial population who is indifferent to the increased silver loads. And that's basically everyone who is eligible for CSRs. They're going to stay on silver no matter what because that's how they get those increased benefits. And the premium that they pay for a silver is basically just a function of their income. As the silver premium goes up, the subsidy goes up right along with it. So they actually don't much care what the premium is pre-subsidy. Okay. So I'm going to walk through sort of the questions that are addressed by the revised guidance. The first one, who should calculate silver loads? Right now, the carriers calculate the silver loads and they do that using their own internal models that are difficult to transfer to the board during rate review. So while this allows them to model very granular benefits using their own internal data, it creates a bit of a black box that's difficult for the board to investigate closely. Additionally, any differences in their calculation methodologies create silver loads that potentially vary between carriers for reasons that aren't necessarily intended. And it could be anti-competitive if one carrier has an artificially low or an artificially high silver load. So both the initial revised guidance and the updated revised, the initial proposed guidance and revised proposed guidance that we're describing here both change to the board actually calculating the silver loads rather than the carriers. A related question is whether or not the silver loads should differ between carriers. This is very similar to that last question, right? Especially on the custom plan designs, the CSR benefits can vary between carriers. They can have slightly different mixes of people and different reimbursement arrangements. So in theory, it might be preferable for the load to vary between carriers. However, that variation opens up opportunities for that sort of anti-competitive goal of producing lower silver loads that I was talking about. There are two states who have currently mandated a uniform statewide CSR load that doesn't vary between carriers and both the initial and revised proposed guidance that we're bringing to the board today have a single load across the entire market. A slightly more nuanced question is what induced demand should be assumed in the development of the CSR loads? So induced demand is an assumption about if you give someone richer benefits, are they then more likely to use medical care? Currently, the CSR loads implicitly assume that CSR members who actually receive in some cases benefits in excess of platinum don't seek care as a result any more than they do from having base benefits. The risk adjustment model actually has factors that account for this and it assumes that people in the 87 and 94 CSR are induced to utilize in the same manner that platinum people are. This was the primary change in our initial proposed guidance was that the CSR loads should use those higher induced demand factors, which increases the CSR loads a modest amount. And the final question is what enrollment should be assumed in the silver loads? This is where our initial guidance and the revised guidance differ pretty substantially. The CSR loads as they currently operate consider the overall silver enrollment and what is the average benefit level that they receive. That includes those people who are on base silver who really shouldn't be. People who are making an irrational decision to pay for a silver plan that has the CSR load in it, even though they're still just getting the basic silver benefits. The revised guidance proposal contemplates doing what New Mexico and Texas have effectively done, which is assume that all of those members will transition into other plans, leaving silver populated only by people with rich CSR benefits. When you do that, the benefits on silver look much more like between a gold and a platinum instead of silver. So the CSR load basically increases to produce a silver premium that is between gold and platinum, which is what the revised proposed guidance looks like. It's worth noting that this is an assumption that has to be made. The observed enrollment does in fact show people in base silver and in the 73 and 77 CSR levels. So this is a summary of what the revised guidance would look like. At the end of open enrollment, the board collects enrollment information from both carriers then based on the distribution by CSR level, the CSR load is calculated based on the difference in cost between those 87 and 94 individuals and what a base silver person would cost. I have a numerical example on the next slide that I think will make that a little clearer. So if you look at the base silver row at the top, that's an actuarial value of 70% by definition, an induced demand factor of 3% for sort of a total cost factor of 0.721, whereas the 94% CSR has a 94% AV and a 15% induced demand factor and therefore a combined cost factor of 1.081. Under the initial proposed guidance, we would take the average based on the observed real market wide distribution which comes out to 0.904 and then we would compare that to the base silver factor and the ratio there is 1.254. So under the initial proposed guidance for 2025, we expect, although this is based on an approximate distribution, expect to CSR load of about 25%. With the revised proposed guidance, we zero out the distribution for everything but 87 and 94 and recalculate that weighted average. So suddenly that factor becomes a 1.02 instead of a 0.9. That's the substantial increase to the CSR load and the CSR load becomes about 1.42. So again, this is approximate based on an estimated distribution but that is roughly the magnitude of the CSR load that would result from the revised proposed guidance. This is just a summary of how the approaches differ. Both versions of proposed guidance change the existing status quo by having the board carry silver loads and having it not vary by carrier, also by using the risk adjustment formula induced demand. Where they differ is in that enrollment deception. The revised proposed guidance assumes that members act perfectly rationally, which drives the CSR load up quite substantially. We itemize those changes on the next slide. So walking from the current guidance to the initial proposed guidance, most of the change is that induced demand factor. So the induced demand factor alone causes roughly a three and a half percent increase to silver and a two and a half percent decrease to all of the other plans. There's then a slight change from using updated enrollment numbers. The initial proposed guidance therefore is that 25 percent. However, we're talking about potentially making that enrollment change, which would cause an additional 7.3 percent increase on silver plans and an additional 5 percent decrease on everything else. So the next slide summarizes what this means in terms of the premium dollars that the actual premium numbers if these changes were made. So this is a format that we've used before to describe things to the board. For each column, we have a dark column that reflects the premium number and then a lighter column that reflects the individual deductible for a given plan. And so under the current guidance, you can see a bronze plan. This is considering a family who's at 300 percent of FPL. That family can purchase a bronze plan for free, but with a deductible that's approaching $8,000. Alternatively, they can buy a silver plan for $4,000 with a deductible that's a little over $4,000. You can see that the gold plan, the premium alone is in excess of $6,000 and the platinum plan, the premium is almost $15,000. The initial proposed guidance you can see doesn't change the silver at all, but it makes the other plans significantly cheaper by increasing the subsidies. And then you can see the revised proposed guidance changes the situation very substantially. And now this family that would previously have had to pay just over $6,000 in premium for a gold plan can get a gold plan for free. And the platinum premium has fallen by a similar amount. This is similar information to present it slightly differently. So what we're showing here is sort of the breakdown of households' income. This is at that same level, which is roughly $75,000 post tax. They are unaffected if they're on a silver plan based on the revised proposed guidance. But if they choose a gold plan, their income that is not allocated towards healthcare increases by about $6,300. These are very major changes. We show here a slide describing just how different these CSR loads would be from what, oh, sorry, on this slide here. This shows just how different the CSR loads would be from what Vermont has had in the past. This is not just the biggest factor that's been considered in Vermont, but also the biggest change here every year. And we do want to caution the board that a major change like this will likely have some secondary effects that are a little bit difficult to predict just because the choices available to policyholders will be so different. One of the larger concerns that we might have about increasing the CSR loads this far is that already silver plans are slightly more profitable than the other plans in the market. And so a substantial increase to their premiums would mean that they become very, very attractive for the carriers in this new environment. So in 2022, the average risk adjusted loss ratio in the market was a 96% and the silver on exchange people were a 93%. If we had used the proposed, the revised proposed CSR loads in 2022 and nothing else changed, which is of course a complicated assumption, then those silver on exchange people would have produced an 84% and all of the other plans would have produced much higher loss ratios. If one carrier was to get all of those silver on exchange people, they would then experience a very low loss ratio and the other carrier would experience a very high loss ratio. So while the premiums drop substantially for households here that does come at a cost that the board should consider, which is the long-term stability of this market, of course, there is no guarantee and no necessarily reason to believe one carrier would pick up all of the silver. But this is just a risk to be aware of. And that is all of our slides. Thank you very much. Did you guys have anything else in addition to the slides? Are you ready for board member questions or comments? I believe we're ready for questions. All right. We'll open up to the board. We'll go light on Valentine's Day. All right. I'll turn to the healthcare advocate hearing nothing from the board. I just want to express appreciation for the board entertaining this. I understand you're going to vote on it later, but and it's good to see these numbers. I understand the concern about abrupt changes to the market, but this I think represents a pretty substantial improvement of affordability for people in the individual market, the vast majority of people in the individual market. And so I think that's, I just want to express appreciation. We've been suggesting that this be looked at seriously and I appreciate it that you are. Thank you very much, Mr. Fisher. And thanks for pushing this on our agenda and having us think about it because it's been a worthwhile endeavor and we'll see you where we go. Any public comment via the raise your hand function? All right. Mike, Kevin, Jackie, thank you guys very, very much. All right. Sorry we got one. Walter, how are you? Hey, well, I'm sorry. I was a bit late on the uptake there. I guess I was just going to back up what Michael said, but also that one of the greatest accomplishments of market health care is if it creates the greatest amount of inequality, and that's what this does too. As someone who's in the market, this is no exception. And thank you. Thank you, Walter. Thank you. Nice to see you. Happy Valentine's Day. You too, and then for the rest of the board. All right. All right. Mr. Davis, him, Davis, how are you? Thank you, Mr. Chairman. This is not, this is, I just wanted to say something to the board. It has nothing to do with today's hearing. It won't take long. I'm writing a book about health care reform in Vermont and I'm making all kinds of, as you can probably imagine, I've got all kinds of questions, comments, et cetera. What I want to, what I would just like the board to understand is that I will, I'm happy to, at any time that I'm writing about a specific person, including yourself, I'm happy to tell you what it is and ask if you have any responses and so forth. That's an old-fashioned press thing, Mr. Chairman, that has always happened in the past. It doesn't happen much anymore because there's not much press anymore. But that's what I'm doing. I just want the board to know that. Up to them and you. Thank you. Great. Thanks. Exciting to hear about your book. Good luck with finishing up the work. And thank you. Mr. Fisher? I'll just pop on for a second and ask. I don't know whether this is an unreasonable question to Lewis and Ellis, but I wondered whether there's any ability to estimate what the potential or likely value this would have to Vermonters across the market in increased federal subsidy? I know that number for families is about $6,000 per household. I can approximate that for per individual, it would be a third to a half of that, I think. I could get you a more accurate number and you might be asking total millions or something. I don't. I can't estimate that super quickly, but that's something we could approximate. That would be great to understand. Thank you. Any other public comment? Okay. Thank you, everyone. Next on the agenda, we have an update on the vital from vital and their quarterly update. And I'll turn over. Ms. Anderson, are you here? I am. Hi. How are you? Good. Thank you. How are you? I'm well. Thanks. I'll let you introduce your team and take it away. Great. Thank you. So as always, we appreciate the opportunity to tell you a little bit about our work today. You have on with me, by the way, Beth Anderson CEO of Vital for those. I'm sorry. No, it's a public call. We have Maureen Gilbert, our director of client engagement, Kara Kalanen, who is our CFO and Sufritz, who is our director of technology. Unfortunately, one of our director team, Christina Schochat, who you used to seeing is out very sick today. So we will be doing our best to cover her portion of the presentation. So bear with us as we try to come up with some of those answers for you when you have questions. But what we're going to run through today is our typical quarterly update. So we'll have some information about some of the, a few of our projects just to give you a sense of some of the work we have going on around development and new capabilities this year. Maureen's going to give you an update on the public education campaign that happened in the fall and early winter on just some of the impacts and new ways that we did some education about patients' choices. We will then give you a little bit of update on our security program and what's happening there. Kara will walk you through our financial performance through December and Maureen will wrap it up with the quarterly metrics about some of the usage of some of our capabilities. One thing I just wanted to say because typically this time of year you might be used to us coming and asking for an actual approval of a review and approval of a budget amendment. But because this is the first year where we've aligned our state contract year to our fiscal year, you might recall in the past the contract with the state was on a calendar year so we were always kind of estimating what our budget might look like based upon a contract that hadn't been negotiated because we were based a full year budget on an actual contract that we knew we were progressing with with the state. We are within our performance at least for the year so far is within the realms of what's outlined in budget guidance so we are not requesting any approval of any changes to our budget which is going to present to you some our performance and what it looks like for the year. And so with that I'm going to turn it over to Maureen to walk us through some of the projects. Great thanks Beth so I'm going to share my screen here. Folks see that? Yep. All right all right so I want to start with program highlights here and as Beth said I will be pinch handing on some of these slides so we'll do my best to answer your questions. We're midway through this state contract making progress on a large set of design development installation projects. These slides that we're presenting today they are not all of our projects it's just a highlight a few of the projects that we thought would be particularly interesting to the board. So the first one I want to share is our work on race ethnicity and language data completeness and providing some feedback to providers about the data that they're sharing with vital. So we know that this data is essential to understanding health inequities and effectively targeting improvement strategies and resources. This is particularly true for our partners at the Vermont Department of Health. They really rely on the race ethnicity and language data that vital collects and and makes available to them. And so we're working with the Department of Health on prototyping some tools to help data contributors understand the quality of the data the race ethnicity and language data that they're sending to the Vermont Health Information Exchange. Those reports these tools that we're prototyping are going to communicate to how many patients of practice is sending vital to sending data to vital about. Sometimes this is just sort of basic information that you know they send the data along but they don't necessarily know okay like what is the population size that we're sending you data for we'll get them that information and then we'll communicate what proportion of those patients had race ethnicity and language information present in their data feeds and then whether that data was usable meaning was it sent in standard codes or has it been mapped to health data standards. We have done a lot of work in the past to map sort of local codes or local conventions into standards that are usable and that you can compare across organizations so that you have a real statewide picture here. The reports they're going to be supported one of the things we realize is you don't ever want to put feedback out into the world without helping people understand how they can improve. So we're going to be supporting these reports with handouts about data quality best practices a webinar about why this data matters and how it's used by the Department of Health to advance health equity best practices for documenting and sharing the data and then opportunities for improving data completeness and quality and we want to be clear that this doesn't mean that we'll be able to work one-on-one with every practice to improve this but we can help provide some guidance and we can also as they replace their EHRs or are working on projects with us we can help them get their data to us in a complete and standardized way. So we're excited to be rolling out those reports I think early spring is the target at this point. Then we're going to talk a little bit about integrating new data types so social determinants of health data. So I do want to set the stage here that social determinants of health data comes in a lot of different flavors. We're going to be talking today about social determinants of health data that comes in from a state-based program so not from a health care organization a hospital of practice but rather from a state-based program. So vital work under this year's state contract includes designing and implementing an approach for ingesting social determinants of health data from Vermont's care management program for Medicaid members so this is the Vermont Chronic Care Initiative and they use a social determinants of health general assessment form that's something that the Agency of Human Services uses more broadly in my understanding as well as a new to Medicaid survey. These are completed by Vermont Chronic Care Initiative clients and then we're working to make a plan for ingesting that data. So we're doing work around data governance related to social determinants of health to ensure that that data is protected and shared appropriately especially when it comes in from organizations other than healthcare organizations there might be additional or new data governance considerations. We're also developing requirements for design of a security model that support the security and privacy requirements for sensitive data and new data types as we think about bringing new data types into the health information exchange. So next project I want to talk to you about is one that gets immunization data right into providers EHRs. So it's our Immunization Registry Query and Response Service. It's something that we launched in 2023, made the first connection here in 2023 with a pediatric practice in Hospital in Northeast Kingdom. We partnered with the Vermont Department of Health on this and what we do is we bring data from the Vermont Immunization Registry histories from the Vermont Immunization Registry right into providers EHRs. They're able to query for that information and pull it into their patient record without switching into any different system just hit a button in your EHR bring it right in and that it does include patient immunization histories and there is the option to include forecasts of future immunization needs. This is live at four healthcare organizations five now. We've got a hospital some independent practices and independent primary care group and we're working on implementation at 13 additional healthcare organizations. So this is one that to one of those nice ones where there's just an immediate benefit that providers can see immediate efficiency gain new data that they were looking for right in their EHRs. So the next project I want to tell you a little bit about is application programming interfaces. So we introduced sort of the what and why of APIs and I think our last in-person presentation we back in I think it was June. So our work in this contract here it includes implementing an application programming interface API gateway which is a secure endpoint and identity access management platform and this work is in alignment with the office of the national coordinator for health information technologies 21st century Cures Act and with federal interoperability rules and what it's going to make possible is receiving fire so fast health care interoperability resources structured data in the Vermont information exchange Vermont health information exchange through an API through one of those application programming interfaces. And it's also going to make it possible to make data from the exchange available via API and that's going to enable new uses of the data that's in the Vermont health information exchange. This is all about getting more data in more easily and also making new uses possible. So some of these possible future uses include ingesting patient generated data and also making data available for patients to access in their health apps of choice. There's an associated identity and authentication management platform and that's going to enable a single sign on service which is going to make it possible for providers that participating organizations to log into our clinical portal vital access directly from their EHRs. It's a simple thing but we do find one of the biggest barriers to use is switching systems and that additional password and login. So if you can let people log in to the clinical portal right from their EHRs to get that information about their patients that comes from outside of their organization we just think that's going to drive significantly increased use of that tool. So lots of exciting new uses made possible through the application programming interfaces. All right I'm going to move now into patient education updates. Now this is the next slide I'm going to share with you is not substantially different from what we put in our quarterly update last time but this is the first time we're sharing it with you live. We did an education campaign in fall 2023. This was our second education campaign in 2023 and this one went a little bigger. This utilized a broad range of media to reach more Vermonters across ages locations and media habits. The campaign ended this December and it had been inclusive of education messages and social media so Instagram and Facebook. We used Vermont Public a radio sponsorship message because we know that that public radio has broad reach in this state. We also did a commercial radio message again really broad reach and then we got that 30 second spot that allowed us to tell a slightly longer story about what vital is and how it shares your health data. We did a sponsored news story in Vermont Digger. This was another new medium for us and this was again an opportunity for a little bit more in-depth content. So we go for for a reach where we can and we go for a more complete story where we can to and try to kind of balance those goals. We also continue to encourage provider organizations to help educate Vermonters about health data sharing. We know that that's where people want to hear it most. They want to hear from their providers, from the organizations where they receive care. So we provide an education toolkit in a section of our website that's specifically for patients to support that education and we're planning our next education campaign and really looking for that to include expanded outreach to individuals who speak languages other than English and I am going to pass it over to Beth now for a security update. Usually I think Sue is covering this one. Oh yes I'm sorry thank you Sue. Hello everybody yeah looking forward to the opportunity to talk to you about our security program. I'm kind of starting off with maybe an expanded view of the overall security program just to give you some more tidbits about the background and the elements of the program so a better understanding of how much work actually goes into securing this data. You'll notice that we kind of toyed played around with putting the infinity symbol and the background of this slide and that's purposefully to keep reminding everybody that security is a continuous process. So we'll go through all of these things over and over and over and over again. So it's kind of hard to tell you that we're doing new things because we're kind of just doing the same things but repeating them and continuously improving them. So at the center of our security program is the system security plan and this is you can imagine a very long document that includes all of the NIST 853. NIST is National Institute of Science and Technology and they publish the 853 standards which are controls that all systems should have in place to ensure security and there's some 400 of them that we would want to review as part of this system security planning process. So basically this document is like a checklist that we use as we tune configure new environments and tune them over the years and we go through one by one of each of the security controls and explain how we are implementing that security control in that environment. Some tools that we use along those lines because it is a lot of work is you know we have security control baselines and we actually have a tool which can somewhat automate the process of identifying the security controls that are needed for every system and help us monitor that they're in place and working effectively. We also use some standardized configuration management tools so Microsoft or other operating system vendors will have configuration management tools that we can use that help aid us in the process of doing those things. So you know I feel like the system security plan is the big piece of our overall security program and helps guide everything else that we do throughout the year by doing a very thorough analysis of the system and making sure it's in alignment with the controls that are specified in the federal frameworks. Certainly though you've heard me talk about this before policies and procedures are at the stand at the center of all of this and it's kind of the piece that we sometimes forget that we've written down all the rules for our security program but good policies and procedures are regularly reviewed as part of this continuous process and they serve as the foundation for everything else we do. Every year we go through third-party assessments and risk analysis. The third-party assessment helps validate how we've implemented the controls and helps us get eyes on things where we might have gaps or things where there should be improvements. The risk analysis is a constant thing that we do to evaluate the industry, evaluate the current threats in the ecosystem and make sure our program is staying up to date. All of the information from that goes into a plan of action in milestones that basically is a checklist of items that you want to review to make sure your checklist of tasks that you have to keep to remediate any gaps that might have been found in any of your assessment or other types of monitoring or and to address any improvements that you want to make to the security program at large. So that's all the what we call the core security program elements. They're the formalized processes that inform the security program over the entire year. But there's what we also refer to as technical security activities and those are the activities that we're performing daily, maybe monthly, quarterly, but that includes a security information and event monitoring system. So this is the system that actually watches over all the network traffic that's going through our systems and all the activities within individual systems and can detect and correlate events to and play them up against national databases of suspect activity and warn us, oh, we think this is something that you should look into. So examples would include Kara, I'll call you out here. Our systems are capable of recognizing that Kara went on vacation and she suddenly logged in from a different place. So they said, is this normal activity? So those types of things really help us keep good eyes on our systems and make sure that anomalous activity isn't occurring in our environment. Same thing with threat detection response. This generally tends to be things like your antivirus or your anti-malware systems. Vulnerability scaling, we perform on a quarterly basis, running a tool against all the systems against national databases of current vulnerabilities that have been detected in software and operating systems and letting us know whether any of our systems have not been patched for that. And static code analysis and penetration testing is something we also do with third parties. So this helps us, somebody can actually come in and scan our network and see if they can break into it and its static code analysis will actually go through any of the code that we've written specific to services that we provide with vital and make sure there's no mistakes in code that would potentially create a vulnerability. So any questions on that? Thank you. Thanks, Sue. All right, on to our financial update and we'll pass it to Kara. Thank you. Great, thank you. So the first financial report is the balance sheet. The balance sheet is largely very similar to the balance sheet that we had at the end of our fiscal year. One account that is different is unbilled receivables. Right now what we have in unbilled receivables and receivables largely represents November's and December's work. At the end of June, June 30th, at the end of our year end, we also had the end that we had the last couple months of work in our unbilled account. But June, we had had a lot of work done so we had about a million dollars more sitting in that account. Ultimately, that was built and collected. So if you were to compare this balance sheet to our year end, you'd see that we were down in unbilled AR and we were up in cash because of the conversion. But other than that, we are, this balance sheet is largely what we would expect it to be. Maureen, could you advance to the next slide? Or can I do that? I think I just did. Is it slow? It's slow, I'm not seeing. Okay, here it is. Yeah, so if you look here, this is our statement of activities and you'll see that through December, we are down by almost $2 million and our contract revenue, which looks very substantial. What we found when we really looked at that is that the way the budget was prepared, it really front-loaded a lot of the work to be completed and the revenue to be recognized in the first half of the year. Our entire revenue line is about $11.2 million. What we're seeing with this contract, number one, we started a little bit later as we were waiting for it to get signed. And secondly, the cadence of work is that all these projects are largely ongoing, but they haven't yet been completed and the revenue hasn't been recognized. And so when we analyze on a project by project basis, what we think we're going to end up is with about some projects that will push into fiscal 25, but those will probably represent about $300,000 revenue. So right now we expect to be only about $300,000 short on revenue. We expect everything else to be completed and recognized in the second half of the year. Again, probably not being completed in June as we had in the last year. Last fiscal year, which was the conversion year from a calendar year to a fiscal year contract, we were finishing a contract. So we saw a lot of complete in December. So we saw a lot of project completions in that last quarter of the calendar year. This year, we don't have that. And like I said, these projects are starting and they're ongoing. So I think maybe the budgeting might have been based off of a completion cadence that reflected more of a calendar year rather than a fiscal year contract. But regardless, when we look at the details, we really do feel like we'll be about $300,000 short on revenue, not the $2 million you're seeing. Personnel costs, we are under budget there and we expect to be under budget. What we have is taking us longer to fill positions than what we expected. We've had some vacancies we didn't plan on. We are actively recruiting and we're working hard to find the people for these roles. We want to get the right people in. We have very specific skill sets we're looking for. So it is taking longer and we are seeing savings in that line because we don't have the staffing we budgeted to have. In the non-personnel expense area, right now we're showing a lot of savings. Again, a lot of this is timing. So unlike the revenue, the expenses were largely split evenly or spread evenly throughout the year. And as these projects ramp up towards the second half of the year, we're going to see a lot of the expenses kind of hit then. We've also added some contractors very recently and those contractors are helping to fill some of the gaps that we have because we haven't hired and we're going to see those costs hit. So as those things hit, what we do expect to see is that the non-personnel savings go away. We think different lines will do different things, but ultimately we think that that will level out. And then ultimately, right now we're showing a deficit for the first half of the year of about $125,000. We think we're actually probably going to have a surplus right now. It's looking at to be about $300,000. That's an approximate number. There are a number of moving parts. So we will monitor this through the next six months and kind of hone in on that. But we think we're going to show a modest surplus, not a deficit. Again, I think that the deficit is just reflective of the ramping up of the projects. And as the revenue gets recognized, that will reverse. And can you advance one more slide, Maureen? This last slide is just our cash flow statement for this first six months of the year and you'll see that we actually had cash flow increase of about just under $700,000. Again, even though we ran a deficit, we were collecting cash that was related to work done in May and June, which June being a very big month of 2023. So that cash comes in. It was around a million dollars more than what we typically do in any one month. So you see the cash number went up by about $700,000. And that's really it. That's where we are today and where we think we'll be as we go into the second half of the year. So if you have any questions, you're happy to answer? Okay. Well, thank you. Thanks, Kara. We'll just save the board member questions, if any, to the very end. Oh, okay. Great. But thank you. All right. So we'll move on to our quarterly metrics then. So our first metric that we share with you is the percent of Vermont patients who have opted out of sharing their data through the Vermont Health Information Exchange. We continue to see a very slight and state decrease here down to 1.07 percent. This typically has to do with as you get new individuals into the exchange. They are typically coming in, opted in, as is our policy. And so as they're added, the rate goes down. We do certainly continue to get folks calling us to opt out of having their data share as well, but in smaller numbers than the number of new people coming into the exchange. So this is the number of vital access queries. So this is queries of our clinical portal by organization type over the course of 2023. So just an interesting way to look at who's really relying on the portal, on the data in that tool. You see some strong use by independent practices, by federal and state agencies. So a lot of that is the Vermont Department of Health. Emergency services are relying on this tool more and more. So our EMS agencies in the state and then some use by our federally qualified health centers and hospitals as well. This is vital access queries by month, and we're seeing some growth here over the course of the year. Also something we're not sharing in these metrics, but I think is worth talking about is we've seen about one and a half times as many individual users with a chart access in the course of the past year. So that's great. It just means we have more people who are logging in who are using this system to get data they need to support patients in their organizations. So we also typically report on queries of the Vermont Health Information Exchange via eHealth Exchange. So eHealth Exchange point-to-point connections were decommissioned during our platform transition, and any new connections eHealth Exchange requires that they be made through their hub model. So we're now able to build new hub connections. So that's a really exciting thing, especially because the University of Vermont Health Network is about to complete their connection with us. We're about to we're working together on completing that connection so they can actually pull that data right into their EHR, and we're also beginning work with Veterans Affairs and the Department of Defense that health system to build and test a connection. So this is results delivery. This is a service we have that typically runs in the background. The 610 health care providers that receive results directly in their EHRs often don't know that it's vital who's delivering those results. This is largely, and you'll see this on the next slide, primary care practices, independence and federally qualified health centers receiving results from Vermont hospitals. And that's laboratory results, radiology reports, and transcribed reports. And this tends to stay pretty steady over time. So really essential service and some steadiness there. As I mentioned, the service is largely relied on by federally qualified health centers and by independent practices. And it's also a service to the hospitals because we deliver the results on their behalf. And this helps avoid phone and fax-based workflows for getting that information to support paid care. And that's all. It's all that we have for you today. So I'm going to stop sharing. I had one real quick question. It was just like two slides ago. I think you said 610 different. Can you actually put that back up? Yeah, absolutely. Okay, there we go. Yeah, that one. It's 610 different health care providers, providers being entities. Individuals. Individuals. And how many different EHRs are you delivering information into? That is a great question. I don't have that for you at the top of my head, but we can get that for you. All right, thank you. Any other board member questions or comments? Yeah, I just got a follow-up question. So when you go back, is it two slides back from this? So where you have the queries? So that does not include... So my question when I saw this, which you may have answered, two slides. That's not a question that's pushed into an EHR. That's correct. This is all information where somebody goes into the portal and they search. Okay. I have a couple more questions, too. So on the first presentation, I think it was, Beth, you talked about making data... No, actually, Maureen, I think it was yours, making data available for patients to access and their health apps of choice. I was confused by what you meant by that. Sure. So this is something that our new application programming interfaces will support. So this is one of the possible new uses. It's not something that we have enabled yet, but it's something that the API's application programming interfaces can enable. And what that means is that a patient could, theoretically, in the future, take their... Like their Apple Health app as one example. There's other apps, health apps, that they're their choice to use. And they could connect that to the Vermont Health Information Exchange and pull their record in to that app, Apple Health, or again, there are other examples of apps they could use to look at their health record in a really meaningful way. Because right now, we are able and routinely deliver patient health records to patients who request it in a large file. But being able to pull it into an app is going to make it much more usable, much more readable, much easier for them to interact with. Okay. And that's a potential future state. Oh, sorry. No, I'm sorry. This is aligned with kind of the federal CARES Act and the goal of getting patients access to their data and making it available for them to have in these. So it's really aligned with kind of O&C and CMS guidelines for empowering patients to use their data and have their data. And then with that API, and you're saying like an EHR, that you wouldn't have to open another... It wouldn't be like you'd have to go log on to something else. Is that you click on it, it opens into the vital window directly versus the data being embedded in the EHR? Yes. So that's another... So through this API gateway that we're putting in place, the authentication part of that API gateway is going to enable us to create a new approach to single sign on. And what you said is absolutely correct. They'll click in and we'll get them into the vital access clinical portal without them having to enter a separate username and password from what they entered in their EHR or their own system. It does not embed the data in their EHR. It's something that they would be taken out into a different environment. Does that make sense? Can I explain that? Yeah. But then there's also this separate initiative to work with some of the hospitals you're working with and trying to embed the data directly into the EHR. Correct. Yeah. We're working on both things. Great. But that's all I have. Thank you. I'm all set today. Thank you very much. Anything from the healthcare advocate? Nothing from us, Chair. Great. Any public comment? All right. Hearing none, thank you, everyone, very much from Vital for another really thorough and helpful presentation. Thank you. You know, I have a nice day and we'll see you soon, I guess. Sounds good. Thank you. I think that's all we had. Is there any old business or new business to come before the board? And is there a motion to adjourn? All in favor, please say aye. Aye. Aye. Aye. Aye. And we are adjourned. Have a good afternoon.