 Welcome to the Green Mountain Care Board. First item on the agenda is the Executive Directation Board. Susan? Thank you, Mr. Chair. I have one announcement and a follow-up item. A few weeks ago, might have been a month ago, we had here at the Green Mountain Care Board a panel discussion on primary care and family practice, specifically, and had a panel that consisted of providers as well as educators. And I want to report out that tonight we're having a special primary care advisory group meeting at the Green Mountain Care Board offices starting at 5 o'clock. And we'll be hearing from members of the primary care advisory group who actually had a meeting with Reisel School of Medicine at Dartmouth and the Indiana Medical School, the Larner School of Medicine. And they'll be reporting out on their progress towards their goals of increasing residency spots for primary care and family practice. So, I'm excited to hear what they said, and I just wanted to share that progress to all of you as a public. And that's all I have to report. Thank you, Susan. The next item in the minutes of Wednesday, February 12th is our motion. So moved. Second. It's been moved and seconded to approve the minutes of Wednesday, February 12th is our new discussion. Seeing none, all those in favor signify by saying aye. Aye. Any opposed? So that will move on to the UVM Milestone Report. And Anna, whenever you're ready, take it away. Thank you, Mr. Chairman. And I would also want to thank the Green Mountain Care Board again for the opportunity to give you an update on the status of the patient's psychiatric capacity project. This is our seventh quarterly report. I'm going to skip ahead of the couple slides that we have here and that these are slides that certainly the Green Mountain Care Board has seen as well as the public that sets the frame for what we're trying to achieve in this project and are in statement. And move to the supporting structure for this project. So I want to recenter us on the fact that we are on the face of design and operational requirements. We have completed the facility programming. The facility location has been identified. And we've spent the last few months in the schematic design and we're finding that, which has given us some insight into the financial impact of the dental visits currently designed. So just to recap, in June of 2019, we came forward with where we were reciting the facility location on the CBMC campus. In August, the facility program was completed for the patient's psychiatric bill and the emergency department. A reminder that approximately 80% of acute care psychiatric conditions are admitted through the emergency department. So we included the planning for emergency services as part of this bill. In January, in our last report to the Green Mountain Care Board, we focused on getting an update on where the facility was being cited. If you recall, we were not able to tear down Mountain View building, which was more proximal to the rest of the campus proper. And so we had to shift where the location was cited. We also had initiated that time on parking study and the exploration of options to enter both the new build and the whole organization that was impacted by this bill. The ED programming resulted in a recommendation for four-bed transitional care unit in the ED. Currently, CBMC has three-bed transitional care unit. And all of that work was done with intense stakeholder input, clinical and support staff input as well as site visits and benchmarking that we had. Since our report in November, we have completed the schematic design. You're going to hear more about that update today. We have also completed the parking and traffic study, and we have initiated a data analysis refresh. So we will give you those updates as well. I think they're important and also inform the high-level cost estimate that we now have ready to. Jim Alvarez, our RUPS support services, will give you an update on the schematic design and before our VP for strategic and business planning will provide an update on the data analysis today and where we are in the business plan development. Okay, so this first slide represents the massing of the concept that we've been working on. This is for you, Jim. Yeah. Wow. So then for Alpha Fisher Road on the lower right-hand corner, you can see that that is an existing ED. And so this concept moves the ED to the east side of the campus on the first layer, the first level, with the two floors of site above that and then a mechanical floor on top of that. And this really didn't mean structure for future mid-search floor as part of our long-term master plan. In massing the building there, we call for the relocation of what we consider our main entrance to the hospital. And so you see the light blue cord that takes you back to a structured parking solution that then becomes the main pedestrian entrance of the hospital that moves to the back in this concept that we've been investigating. How much more land is there behind what is shown on that slide? So we're directly up. Up is the Woodbridge Still Dressing Facility. To the right is the highway, and then to the left is what we call MOBC, but it's a medical office building that we do not own. We own two lots after that. And there's also a ravine that's behind the physical plan. Yeah, and the last slide will show an overview of the site. I think the pointer is in the middle, isn't it? Ah, there we go. Perfect. So this is the program that we have been working from in schematic design, which is six TCA beds, eight Tier 1, 16 Tier 2, 16 Tier 3, Tier 1 and 2 located on the same level with the central core, and then Tier 3 had been being able to separate off that we did too. And really the flexibility of the design has been kind of an overarching consideration because care changes over time. There's time between this stage and when we're just seeing patients and everything that was evolving. So we want this building to kind of have a long lifespan in the relevant terms of cater. And so the flexibility of the space has been an overall theme throughout the process. So on this slide is the ED level. This is the TCA that we're talking about. And remember the program, we said six. So you see four that represent this TCA area right here. And then we have two that are medical, surgical, all swing runs to 10 on which they need to be. They can open up into the TCA or open up into the ED to allow flexibility of the space. Also the space can be divided into sections to consider the appropriateness of the patient mix in the space of the time. Ampliatory, our ambulance entrance would be in the back side here through this vestibule. If it's a medical patient to come down this corridor to the appropriate area of care. If it's a site patient to come through one of the intake rooms and then into the space. The space has a secure elevator that then goes vertically up to the inpatient site unit. Ampliatory entrance is on this side with the waiting. And then this is broken into two pods. One would be the main pod that's open all the time. The other one reflects up and down throughout the day as the volume necessitates it. So you can imagine that normally the rush three to 7, it's 5 p.m. to 7 p.m. All units to be open, but from midnight to 6 p.m. we may only be on one unit because that's a lower volume time. So it allows us to be much more efficient. So going up one floor, this is the tier one and tier two units with the central support board. Each of these units have access to outdoor space which we've heard from bureaucrats how important that was. The tier one does have an area that can be divided up if needed be. There's also some flexibility around the living dining area. The tier two, also some flexibility around the living dining area and its access to the outdoor space. And then this is, I received from the side of it, I think this is the vertical one here. Tier three is the central core in the two distinct areas to that. Again, its own living dining. It has outdoor space on both sides of this. This floor has done a lot of time about flexibility and how it would be used over time. And so it's really geared towards being able to provide the right kind of behavior. Should we have a need for more tier two beds then it actually can advance to a tier two if we need to. This is the overview slide that I was talking about. This is some of the stuff that we have been discovering in the process. And so we originally changed the concept from L right here because of what we call MLBA, the mountain view right here. So it remains without the building of it being more rectangular than they held and originally pursuing. This is that corridor that we didn't come through and connect to the structure of the parking solution on the backside. And then this would be kind of the new entrance of the hospital. One of the constraints that we originally thought was an unchangeable or immovable constraint but the power lines are not across the campus. It also required easement to it that we can't build underneath and you can see the impact it had when we built the oncology center right here and how that has that funny wall is because of that easement right there. Velcos agreed to move the lines. We got to pay for it but it would move the lines this direction and then opens up the campus to much more opportunities. What's the cost for that? I think it's going to give you approximately two main numbers. Two main? Yeah. This is a tad less because the original is the estimate we have right now around that. Another interesting fact on the site is from where you see the teleporters right here to what was traditionally the main entrance of the hospital is an eight foot elevation difference and you don't really notice it now as you just walk up below the CP and you push a building out to where this one pushes up to. You have to solve that eight feet and make sure it distance. And so it was a constraint that the Arctic spent a lot of time trying to figure out how to not build a huge retaining wall and have to overcome that. So they have solved it in a way they're going to create a lot but that was an issue that we had spent a lot of time on. Also the geotechnical analysis, we learned that the ravines right here at one point that ravine was all the way across here and at some point in the history, I imagine before the hospital was built a during its construction, it was infilled with whatever they had at a time which makes it a fairly unstable place to place the building so we had to mitigate those unstable soils to build here. Is there anything else that I would like to talk about kind of the main parking points? I wanted to tell you about three pieces of work that we've been engaged with over the past several months. First of all, we had shown you quite a while ago the methodology we used to come up with the number of estimated additional inpatient adult psychiatric beds that we needed and we felt it was time to refresh that data and update it. So we used the same model that I explained to you last time and we've used now data from July 1 of 2018 to June 30 of 2019 and run that through the model. We are now in the middle of internal and we will soon start external reviews and we'll do the same thing we did back with the original model taking our expertise both internally and externally to say, hey, this is our best shot. What do you think? Have we done a good job? And we'll take that feedback back, refine the model and go. I think the other very large thing has changed between when we originally did the model from today is that we have two additional sources of potential capacity that would influence our statewide need. And so one is the 12 additional level one beds that are planned to open this spring at the Brattle River retreat. And the second piece that I think could have a measurable impact on that estimate of need is the new 16 secure residential bed that's happening at middle sex. And while that's only a new increase of about nine beds if I remember in math is correct, it's still important to get together and consider what the impact would be. So we're in the middle of engaging in those discussions and I expect we have some settled thinking about this by the end of March. Oh, thank you. Sorry about that. We can go to the next one. Yes. Thank you. We've also been working on two models to develop our financial performance. So with some really beautiful work done on the programming document for the inpatient psychiatry units and for the ED, we've used those and the floor plans that Jim showed you as the basis for talking about what's the staffing model we would need to care for these patients appropriately. What kind of ancillary services do we need? What other kinds of expenses would we expect to put into an operating pro forma? So that work is well underway. We are through the first phase of our internal review process. There will be more happening, but it's a lot of work and we're making very, very, very good progress. The second model is a reimbursement model. So we're also thinking, okay, we know how many beds we have in the proposed facility and then are building up on a tier by tier basis what we feel reasonable reimbursement assumptions and methodologies would be. Right now we're using kind of today's payer mixes and payment assumptions. We used, as you can see on the slide, we brought in some external stakeholders to help us make this better. The conversations have been terrific and we're very grateful to all of the folks from the Green Mountain Care Board to the Department of Mental Health, to Alicia Cooper and Diva. I can go on and on. Tom Bore is from OneCare, but they've been great conversations. We feel that collectively, we feel that we have a good methodology for today's payment picture. Our next step now is to go and think about future state scenarios. So what will our reimbursement, what could our reimbursement picture look like in 2024 and 2029 and so on? So I think that's the good work that lies ahead of us, but we've got the right people, I believe, around the table to do that. So all the work today has rarely informed the process. We've been committed to continuing to be transparent with work and engaging stakeholders. I can tell you that in the last three months, some of the discoveries that we made is part of this very thorough process. It eliminated some challenges, some of which Jim has reviewed with you. So a brain difference of nine feet and fill that is not suitable for a build of this level of height and weight are all challenges. Solving for those challenges is a cost. And so each one of those challenges that came forward, we've been working towards what would the appropriate solve for those challenges be. So as soon as we had some high-level cost projections, we included those in the green-run report and we're presenting those today. The challenges that we discovered, as I mentioned, are the unforeseen building site conditions. I don't think any of us certainly were here when the building was built in 1968, or some of us weren't, and we had no idea that the fill was of the level of quality it is. So to get down to bedrock would be quite a challenge. Again, the architects and the geologists have solved for that, but there's a cost. So what's the cost of that application? We don't have definitive costs at this time. We will buy the next report. They're still underway their high-level. So what we're prepared to share is the high-level overview of approximately under the 50 pound total for the entire program. The additional complexities of interfaces with this building. I'll point to that under 50 million just the innovation that's like that. Just the beds itself? Yeah. I don't have that level of detail with us today. I mean, something we could provide at a later date. We're working on a total project cost, and so anything that we would do to break that out would be on allocators for footed invasions of some kind. And so, I mean, how do you allocate how much of the cost of mitigating the front entrance to the site how much do you mitigate or solve in the 8 feet how much is really assigned to the site and so we kind of figure out a methodology for this option in some of the detail. Can I get that? I just get some frustration off my initial. Yeah. Clearly, we as a board were very interested on campus. Center for Mont Medical Center is a hospital that we're concerned about because it's not in the black on the operating margins. And so we need to have that overall picture of what the future is there. But then we have to separate that out from a particular order that we made two years ago which was just for inpatient acute psych beds. And I think my fellow board members, although I haven't had a chance to talk to all of them individually probably share my frustration whenever there's a delay and then there's the you delay it's just you know it was a tough decision at the time for board members whether or not to do across the board commercial rate decrease which would have benefited all the monitors at the time and at the time the board felt very strongly that there would be a lot of consumers by you know addressing the shortage of inpatient acute beds and so the order was pretty specific about the $21 million towards inpatient acute psych beds and in your written report that you sent to us the $1.1 million includes a lot more than just a focus on those inpatient acute psych beds. So we're going to require that the milestone reports which are specifically for the inpatient acute psych beds should only include those dollar amounts that relate to that and not to designs for a new emergency room or things like that even though we're very interested in that. But as far as us tracking the flow of the $21 million we want to make sure that all that $21 million goes towards the construction of inpatient acute psych beds. So that's the first frustration I think I see in the audience I saw and I thought that his piece in Digger really was a reflection of everybody's frustration that nothing happens quick enough and as someone that's done a lot of construction in the past myself we would have loved to have the most lavish theaters when we were building them but when we sat down the first step was to design the least possible alternative and then figure out from there what could be done to that to make it more attractive to the patrons as they come in and so it's kind of disturbing that here we are two years out and everybody's overwhelmed at this huge cost estimate which is way beyond what anybody had envisioned and so I'll just leave it at that I've got it off my chest but I just want you to understand that everybody's very frustrated as I'm sure you are too I can see it in your face as you share that frustration and it's not always easy but we have to try to figure out if there's any way that we can make up the difference in the time that's lost because everybody's going back to the drawing table is there anything that could be done to try to expedite the construction without costing more dollars and things like that I'm done with my rant so thank you for expressing your concerns and I would say that the team feels to your point some of the same frustrations the challenge with building a complex structure of this which we were committed to making a part of an integrated part of a health system campus is that there are challenges with that there's no doubt and those challenges are class the process that we use I'm comfortable with the notion that it is pet experts around the table we listen to the peer advocates and I will assure you that no one was trying to design something that was exorbitant or I think the design both the program design and the schematic design were very thoughtfully done it was a very innovative process and so I just want to reinforce that the challenge when you are building on a campus that's already cited is that you identify which we have in the last three months challenges that were not foreseen and I'm not trying to mitigate the fact that a nine foot difference between the entry of the campus and where this new building is cited is a significant elevation difference how you enter the building and exit the building and keep the rest of the campus functioning was also a significant challenge we didn't know some things pop up immediately tonight like you don't have to do soil mitigation can't you take that and you've got to remove and build up the helicopter pad so it's at a higher level because that only has to support the weight of the helicopter and then you're replacing the fill there I mean it just seems like these aren't insurmountable problems if the right people are at the table trying to figure it out and we believe that they're not insurmountable to be honest we think we can find solutions that will keep programming work and schematic work is not lost that work can be repurposed coming back to what is going to be core working with the design teams as we have to meet the goal that we set for us which is to impact the care and treatment of adult and patient psychiatric pain we're still committed to that we're still committed to doing that in a time frame that is as realistic as it can be when you're building a healthcare facility versus another type of facility or non-healthcare facility so we are still committed to that we don't believe that this will set the entire project back significantly but I would also we've been very transparent from day one that's something we are committed to and you know what we know right now I can tell you that we are also are committed to is taking all the good work that's gone on so far and going back and looking at things like can we do this in a different way that still maintains the program that still maintains the schematic design that was very thoughtfully put together by all the processes we have and can we mitigate some of the cost so we're committed to doing that and I'm confident that with the reward of this team and others that have been part of this process we'll find a solution that isn't 150 million what's the time for finding that solution we're looking at at this point about six months what's the target range of what it costs to come in so that's a conversation that we're having internally within the network and we're meeting this week to understand exactly what is that number so that we're very clear so we can drive to that we did not go in I think you know this from the reports we didn't go in with a number in mind we went in with let's design a facility that will meet the needs of the patient through the process that we've described in the previous six reports that was purposeful that wasn't by happen chance that was the recommendation for people that build these type of facilities all the time so what none of those people could have identified is some of the discoveries we've made on our campus we didn't even know some of those things existed as constraints and mitigating those constraints over costs I do believe that we're going to come back with something that is much more realistic and still maintain and we are committed to still maintaining the alternate role which is to ensure that psychiatric patients receive inpatient acute care in the appropriate setting that's our commitment but I appreciate your expressing your frustration how was the six months of that construction timeline because you see it's certain months of the year they can do things a lot so does that mean that it pushes it back? I think we'll know much better once we have the concept and so I think generally in order to shrink a project from the size of something meaningful being scoped if the size of the building where we place it then it could compress the 30 to 36 months we were kind of thinking construction would take and so that's what we're thinking we may not have affected the overall timeline that much because I think we're going to make it up as we keep going through the process so I think part of what you're seeing now is we're sharing what we discovered and maybe we're still working on a solution and so the next time we're in front of you we're having a meaningful conversation about what we learned from this and what is the next step is there a way to do things with the current plan that's available that you don't need in part to interrupt you? what's difficult about the site is that what the study showed us is we're short 44 spaces right now just on a normal day and so any time that we take any part of the campus put a building on it we create a height in the problem there's also I guess there's a the concept of are we really okay to continue to cover green space with asphalt and parking cars for acres isn't it more you know socially proven thing to try to compress to how much green space we're covering with asphalt and so I don't think we should be scared of a parking structure I don't think the solution because I think we can solve this particular stage without a parking structure if we rethink the scope but I don't think that in future conversations we ought to be afraid of it because we're really taking up beautiful Vermont green space and we ought to think differently about it I will tell you also that part of the discovery we have been told at least certainly from my tenure and the other master facilities planning that we've done that the large transmission lines that was just a system property and you can tell any previous buildings before my tenure they actually designed a building with a corner cut off for that easement it was illuminating to me when I first rounded through that building to understand why would you design a building without a corner that's not there anymore and then it became clear when we saw the area why that was it was the easement issue so in the past what we've heard is that's that's a constraint can't change that I'm grateful to say that in our conversations with that company they are open to shifting where those power lines are resided that opens up an opportunity for us that didn't exist even three months ago so it's a cost but I think that cost will pay returns and that it allows us that was a huge constraining effort for us we could not build in that area so we may be able to cite this point in the physical location of this building in a slightly different way that will keep us away from the ravine, get us away from that gradient difference so again I'm not convinced that we haven't looked at all those potential options but that is part of this journey you're discovering one thing at a time and clearly all of these lessons learned will inform the next phase of this work it's really important to reinforce again we are absolutely committed to not wasting time doing this work we are moving as quickly as we can we've been committed to moving quickly I know it's not quickly enough for patients that are waiting to face around the state I real understand that I'm a clinician I understand that very well we are committed to trying to solve for this in a way that's economically feasible not just for the network but for the state of the law because we are committed to that questions from the board I'd like to go back to the discussion a little bit about rewriting the models to see kind of how things sugar off today as opposed to when we did it last time and just kind of wondering when we went through that process which was an elaborate process we ended up with a 25 to 29 bed range and then settle on a 25 bed range and I mean it may be but I think that in terms of you going back and running the model again is that more for information sake or is there a purpose behind it to adjust the number of beds thanks for your question there's two reasons that come to mind right away about why it's important on the model and so one is are the assumptions that we originally had still holding and I think we could say for example are we at full capacity with our current patient adult psychiatric beds I think we all know the answer to that the impact of that with borders continuing to be in all of our emergency departments but we also wanted to check on length of stay assumptions and so on and so forth the other piece is that there were pieces of that work that informed how we designed the number of beds we needed in each of the three tiers that we designed for the building so we wanted to see if within that number any of the next change what isn't changing is you'll recall that we came to you and said the maximum number of additional beds that we can build is 25 and that is to keep to ensure that CBMC does not run into issues with the IOD requirements so that's clearly kept in mind so you might say that anything above 25 additional beds is a little bit academic if you will we will not this doesn't have to be a very long process again all of the hard work we've done into that original model again we're leveraging that very quickly so I hope that answers your question it does it says it but a small takeaway I take that as that the number of beds might go down things aren't totally cemented yet but the number of beds might go down it's definitely no no because it was of the number of beds you can have one facility just to remind you that actually the initial estimate of additional beds we needed was between 29 and 35 when we factored the future growth in some of that helps set the stage with our IMD analysis said the highest number of additional beds we could build was 25 so as I recall I forget the exact number of psychiatric beds that we have now it's like 13 15 and so if you take the 15 and you add it to the 25 which is kind of what's in the plan now could change could we go back to the schematic and show us where the are the beds that are in these tiers do they add up to the total number of psychiatric beds so that should be 15 plus 25 that should be 40 beds right and so today's program is 8 to 1 beds highest acuity patients 16 tier 2 medium acuity if you will and 16 tier 3 in the program I requested and that adds up to 40 that adds up to 40 yeah I mean I want to underscore a bit of what Kevin had to say I was new on the board at the time and it was my first no vote in terms of of this project thinking that the staff came to us originally in March of 2018 and it was asking for saying it was used to $21 million for a 3% rate cut and you know there was an option I proposed it didn't even get a second so maybe it wasn't that good but I liked it but you know so but the point I'm trying to make is that that we were looking to put that money to good use and with these psychiatric bed concern was prevalence throughout the entire system I know when I was going to hospitals you go into the emergency room you see people behind the curtain there was a gun I mean the need was unmistakable and I applaud Jess for taking the lead that she took on this issue but I think that our sense was that this is something that's got to move pretty quickly as fast as it can this $21 million and the wording in the vote is solely for these beds and I'm worried that now things become entangled and that we can't keep things kind of clear and so I go to the letter from Dr. Brumsted on page page 8 of 16 the last budget report that we got on the $21 million before the most current was in May of 2019 and the total was $94,000 at that point in time and this letter reveals that and that number is up to $1.1 million but it's I assume that these numbers that's just not associated with the psychiatric beds that's the parking garage and the emergency department et cetera et cetera so I'm kind of going back to where Kevin was is what is the benchmark that we should be looking at as to what is a reasonable cost for psychiatric beds that can track that in my kind of amateur approach to it I have done Kevin's construction in my life but in my amateur approach to this is just to go out and see what are the costs for bed for psychiatric beds in projects that have happened in the last two years and I found a number of them and the range is between $340,000 a bed and $534,000 I have no idea whether or not that's an important north star but I am looking for the north star on this what should we be spending for psychiatric bed and to have it tracked in a way that it doesn't get lost in the overall massiveness of this project I think the total project is much bigger than the cost by beds and I am just worried that we lose track of the cost associated with beds so thank you for expressing that what we are doing as we evolve this project is to try to become more clear with what the cost is for each entity or portion of this project the challenge with a project like this is building a standable psychiatric facility in a brain field space if we weren't doing that likely the cost would be significantly less we are building adjacent and this was a desire expressed by many that the care of psychiatric patients be normalized in part of care as part of an integrated health system so we've committed that that as a network makes sense in a central location like Central Vermont the other pieces that have accompanied this have not been ads that are not related to the care and treatment of psychiatric patients so the addition of the ED into the project we became before the board and saw approval to move ahead with that planning was based on the data analysis that showed that 80% of our patients that end up being in a acute care setting and requiring acute care come through the emergency department our emergency department at CDMC is far distant to where we were looking to cite this which would make for clinical and safety issues for transferring those patients from the initial site of entry into the organization being a current ED to where this bill would be occurring and where it would be eventually cared for so we moved ED into the planning and accelerated that process so we could keep it conjoined with the care of inpatient psychiatric care as well so each of these additions have not been added without care and thought around how it relates to our primary goal which is the care and treatment of inpatient psychiatric care so all of those additional pieces do add to the cost and that I mean honestly that's where we are and so what we identified what that number was and again it's high level cost estimate we're going back and we're saying we know we can't afford $150,000,000 we can't afford it as a network we don't think the state of Vermont can support it as well so we'll need to go back and see like power lines being moved can we cite this in a place and address some of these issues again all with the focus of addressing those patients waiting in these across the state of Vermont every day that's our primary goal we had as much interest as anyone trying to do this as quickly as possible we also are committed to doing it as well as we can we have the input from all the stakeholders that have been part of this to date I hope that helps to give a bit more context on how these other pieces have been added I think what we can do and we'll certainly take back to our team is can we divide the report going forward so we're more clear around as we have more clarity on the actual cost or just the bends what that cost is we will do our best to do that I think the challenge is allocation of things that Jim was describing of how much of what we're doing is associated with this population and that becomes a little bit more of a challenge but we will certainly take that feedback back and see that we can do that more clearly going forward one more question we have one point in time when there was 150 beds at Waterbury that was entirely a state supported entity as much of an antique as it was I mean it was a totally state supported and the facility the psychiatric facility that's up on the hill with you is also entirely supported by the state and I I'm just wondering if you have any expectation that non-healthcare funds that state funds will be available to you to help with this project what I can say is that we are here to have those conversations with the state of Vermont to explore the potential for support to meet this need for the state one more question just a couple one is a programmatic question and that's with respect to the recent concerns about the financial viability of the grab or retreat and the recognition or the highlighting of the fact that that's the only place in the state that takes care of children and adolescents maybe this is for Eve as you're going back through the model of beds and thinking about beds and programs is there any sense in which thinking about having some beds capacity for children so that we don't have all of our eggs in one basket so to speak diversifying a little bit okay that's fine part of the decision to focus on the adult patient population was one based on the data that was the most the other piece was keeping in mind that we were going to provide the service within the Central Vermont campus proper Central Vermont does not currently have a pediatric inpatient program so that is a huge limiter in the care and treatment of pediatric psychiatric patients so we are looking across the network to see if that capacity can be managed within the network or a care and treatment of pediatric patients but that was the limiter of why we're focused on the adult population again totally I'm reading that the need for pediatric inpatient care is real it is not in common for us as well as ED around the state to have pediatric patients waiting for extended periods of time clearly not therapeutic to do that in ED do not currently have an inpatient pediatric program Central Vermont that our children's hospital is sighted in Chippin County at the EDM office and I guess my second question is to follow up to that as you're thinking about your whole network and I would ask also as you think about the entire hospital system in Vermont given that there is going to be a delay and I understand the reasons for the delay and I appreciate all the efforts that you've undertaken to think carefully about this do you see particularly as a clinician and people who are really involved in this needy from the data are there any short term measures that we can do in the meantime especially now that there is going to be a delay increase throughput to provide I just wonder if you're seeing any opportunities for us to at least help in the short run and I mean us broadly the state I mean the network I mean Voss I mean whoever where do you see some opportunity I think the opportunity is to continue the strong partnerships that we have with the designated agencies around the state I know speaking for Central Vermont Medical Center we have a very close relationship to Washington County mental health we work with them collaborating on a variety of programs to keep patients outside of an acute care setting and we've partnered very well with them even in our EDs to have peer support available for patients that are coming in that have psychiatric condition and to the degree possible we and I know we're not isolated in this other hospitals in the state are doing this are ensuring that we're only providing acute inpatient care where it's absolutely necessary so those kind of interventions and partnerships are on the way we're very grateful for those we're also looking at a number of other initiatives we spoke early on about a strategic plan for mental health and new partnerships with mental health in our primary care so co-locating on psychiatric resources within our primary care so we're treating the patient holistically not just their medical physical health but also their psychosocial health and so we're committed to as a network in particular advancing that notion of that partnership happening in primary care and care and treatment more proactive versus the care that sometimes we're in now which is a very acute or emerging care phase where those individuals are coming into our ED that's part of my population health focus that's part of the direction we're moving in and I think we and I believe we said and continue to say those partnerships are critical that what we're solving for even with this with all the work is only one log of that log jam of psychiatric care in the state of Vermont and we will continue to explore those opportunities to do that outside within acute care setting absolutely. So the capital campaign being conducted now to tie up to this project? We are prepared to to launch a capital campaign to support this work to do that we want to be really clear what we're going to be campaigning for but certainly we've actually recently hired a development officer for our organization we're very confident that that individual along with the support of the network will launch an effective capital campaign to support some of this work yes absolutely. It seems like a large portion of this project is more than just the site beds and it seems like the community should be rallying behind trying to bring the hospital into what I would call modern times even as part of the second if there appears to be some real opportunities for fundraising take a look at for example the rooftop gardens you would think there are probably several donors that might want something family roof garden in that hospital so hopefully that will be very successful in that campaign. Any other questions from the board if we're going to open up the public, Robin? I was curious if a recent strategic plan of the Department of Mental Health came up with how that has informed your thoughts about this project or if that's really been incorporated yet. It certainly is new but we are taking that report and digesting it with our colleagues in the Department of Mental Health and seeing what of that that report would be impactful for us not just for this project but for the long-term care of our psychiatric patients. It's always helpful to have that kind of resource available. At this point I would open it up to the public. Dale Some of it I had trouble hearing so I apologize if I'm asking a question that may have already been answered but as I'm looking at the diagram I've got some concerns and this one isn't as good in detail as what was up there but in the parking garage so far away has been concerned about access issues the people that are coming to visit the hospital are not always they aren't just runners, they aren't just people that come off for miles they might be in wheelchairs they might have walkers and I've seen this happen in other designs they don't think in advance that everybody is not healthy that is pulling into the parking area so what's the possibility of taking the parking garage you're moving it up to where you've got the actual roof gardens and putting that actually where the parking garage is would that increase your ability to then expand would it also increase a better flow of traffic around it and assume some things as far as what else could be changed in the design and I don't know what the cost is and what I'm referring to but you look really and I think Howard Park has more parking than what you've got in front of your chair 1, 2, 3 thank you so we spend a lot of time trying to figure out the placement of that parking and we actually try to solve it more on what would be the west side of the campus and it put the parking so far away that it actually caused the problem that you were just describing back there you have and we are envisioning that first row was Handicap Park Accessibility Parking and then right to the Sky Bridge then takes you directly into the building into the lobby and so when we did kind of the preliminary study about the travel path this was the shortest route but also the trying to outside the ED a lot of that would be accessible to parking too through the inventory entrance of the ED and so we did a lot of thought into just what your concern is by flipping the building to the back side it causes some issues where you think about the long term master plan of the campus and how it is but also in terms of the ambulance traffic now we force the ambulance traffic to circumvent the entire campus when this pedestrian is going through another car is going through trying to get to the ambulance entrance and so all those conversations kind of form the masses here right now follow up question hold on to that and I'll come back to you Representative Donovan thank you I just wanted to comment because I've been very deeply involved on the work groups that have been spending a huge amount of time and energy into helping discuss inform the design plan and first of all I really appreciate and want to let the Board know because the Board had said work with stakeholders and they really have very extensively and listened to the input and integrated it playing a part in it so from that experience I can let the Board know it wasn't just about fitting with the master plan it was fitting with what's the best delivery of quality of care and there was a lot of thought and planning it is a big disappointment that it's not affordable to move that way because from a construction point of view from a patient care point of view for all patients in the hospital it really was a good plan and well thought out and now it's got a shift course and it will be less ideal in a lot of ways but it is important to move forward the other thing I wanted to just help with a little bit of context because I was also very involved in the Vermont psychiatric care hospital construction and so just as a reminder the cost there was a little bit over a million dollars a day it was more than a million I forget it was somewhere in the range of 25 to 30 million dollars for a 25 bed hospital and I guess I would disagree slightly that a standalone is not necessarily less expensive because you've got a lot more infrastructure you also have to add but if you think of other hospitals I think the Miller building was the range of a million dollars a bed I think that's for better or for worse in Vermont that is what it costs and what's important to remember in comparing to other psychiatric facilities is psychiatry is very different now psychiatry is finally recognized in its integration with all sorts of health conditions and particularly with our aging population and the easiest small example is by codes architectural codes psychiatric bedrooms are permitted to be smaller you don't have all the equipment needs and so forth as we got into the design and planning here we recognize they needed to be medical size rooms because of the need for at least some of them right away to have that medical capacity but for many more of them with the aging demographics to have the connected medical capacity which requires more space so right off the bat that's adding a square footage so it's something to keep in mind in terms of that you know cost per bed and the last piece is intuitively say well this is a million of bed we're doing 25 beds that's 25 million not 40 or 50 million but the last piece is to if you think about having 25 psychiatric beds in one part of the hospital and 15 on a different floor in a different section just in terms of operational savings and quality of care and so forth you wouldn't want to split those unless there was some really easy connection that turned out to be feasible so it really is about a 40 bed project not a 25 bed project in terms of how you would want to have an overall psychiatric unit so I just want to commend the work I know it's unfortunate that you know the hoped for directions and I think before I got here they explained some of how that happened but I think they were doing really excellent work and the stakeholder voice has been actively involved and it's much appreciated. Yes. Yes, first of all, Lou Anna, Jim and Eve. My name is Dan Toll I'm a worker and volunteer in the mental health community across the state of Vermont for such entities as Pathways, Vermont, NAMI, Vermont and Department of Mental Health's Adult Standing Committee and as the team knows I've been a part of the PIP design team for the project that we're addressing right now I've been representing peer support workers as well as the voice of someone who has mental health lived experience and has actually had unfortunately three visits to the psychiatric unit on the third floor of CBMC and I say unfortunately not that they didn't treat me well but no one wants to be in patients like trust me. Despite the frustrations among various stakeholders regarding the unexpected high costs and this two-year estimates there are many of us in the mental health community that see a silver lining here. This pause and reassessment gives the project leaders a chance to step back and take a look at less restrictive more effective and lower cost options than inpatient psychiatry. Specifically, I don't know what I'm referring to and you're probably all well aware this is my first visit to a Green Mountain care board so I hope to excuse me if I'm not addressing this appropriately but specifically what I'm referring to are such things as peer respites and two examples are the Alyssum facility in Rochester and the Sotirian facility in Burlington as well as the use of the peer support workforce and of course as for those of you who've read the 10-year DMH plan peer support is an integral part of that plan. I know because I was part of the think tank and I'll craft that very wonderful document that I hope everybody in the state takes seriously. So what I'm interested in from you folks is what is your current thinking about doing a more comprehensive evaluation of the full spectrum of mental health services from the most restrictive prisons and inpatient psychiatry units to the less onerous and lower cost community services. Your comments. Again, as a metmobium health network we're committed to making sure that the care delivered we provide in our acute care settings or our practices making standard of care and optimize outcomes for psychiatric patients so we're very committed to that. We also as expressed are committed to continuing the partnerships that have been so rich I think not only through this process but even outside of the scope of this particular project. To respond to your question of are we in a position to step back and really look at the whole scope we would rely on those partnerships and continue to partner with the Department of Mental Health to inform in the ways that we can through our clinical clinician involvement and other involvement in that process to be part of a full state solution. I don't feel like I'm in the right position to speak to what our commitment would be to that but know that we are continually committed to partnerships that continue to inform the care and treatment of psychiatric patients within the state and also with our national colleagues and their academic health networks. Thank you. Ken, did you ask that question? Yes. Thank you. I haven't I'm sort of a new person too because I haven't been here for several years. Since I've had an opportunity to write a piece that I think you've all looked at I'll try to make this less than 30 minutes of reasonable questioning. It turns out I mean it is interesting it's almost a year of the date that we all sat here it was literally a date when there was this common agreement after a lot of work to resolve that there would be a 25 bed facility and that was a big moment and I stood up here and I said one key ingredient is to expedite this project and I have to tell you the chair exhibited great patience and today I want to accuse the chair and the board of having unbelievable patience it takes my breath away how patient you are because I have to tell you that this delay is a devastation to the mental health system in the month and I will definitely agree with others it has been a pleasure working with the team I said that last year but the product is unacceptable and I'm almost a little shocked that there isn't more of concern not only about the money not only about the planning process but about what's happening to patients in this system if this project is delayed another two years and I do want to tell you that the consequences are enormous I cannot really explain how good people and I'm part of the group although I may be voted off the committee or something how good people could come up with a $150 million figure I'm just stunned and the fact that there isn't more of a pushback and there is some pushback but it defies reason we don't have time to go back and review and with all the words which I think are really heartfelt to a logic stand as far as I'm concerned you've been given a blank page today with very little on it no dates no certainty, no cost and so my question is perhaps the time has come one to decide whether you want to go ahead with this project assuming that it's going to be in person in 24 if everything goes right now and are there other alternatives or are there other alternatives that the University of Vermont could look at that the Senate could look at to say we have $20 million to do some planning so that's one question the other question is does the board want to consider setting some boundaries in limits maybe the board should say $40 million is sort of the out of most range that's practical I think the psychiatric senate cost about that a little less actually in construction and at least set a marker so we don't come back with a figure that's just not doable particularly in Vermont there's a lot of expertise here on the table it shouldn't be kind of just a fishing trip and it's hard for me to believe that in the next month or two you won't come up with a figure to say here's the range that we're going to work in the other issue is and I'll go back to I think Tom Pella who did I think have a good suggestion which is to say instead of just turning over all this $21 million perhaps there should be a lot more guideposts to say if the product isn't coming despite all the good work and good intentions and good people maybe the money has to then be removed and used elsewhere or the money has to be returned so those are the kinds of questions that I have and I appreciate your view well Ken those are all the same questions that are probably going to reach one of the board members should we open it up to others to use dollars to try to come in with a project that actually makes sense but if you do that you're going to write back to square one too and so I think that at least from my viewpoint what we really need from Central Vermont Medical Center and UBM is a separation of costs because certainly we could set the parameters of what the psych bed costs should be and I think $40 million probably is a fair figure for that but then you've got to tie in everything else that's going on here on the campus and things like that and I don't think that the building of psych beds should get slowed down by an overall redo of this particular campus so those are things that I think everybody is thinking Ken and what can be done to do things quicker one thing that automatically pops into your head is listen Miller opened with that previous space could there have been opportunities to create psych beds there similar to what Rutland did with an existing floor space and converted that and even using that existing floor space I think they came in around a million dollars too so anybody that thinks we're going to get something on the cheap is just kidding themselves but on the same token I don't know how you go back to square zero and start again I think that the clear thing to do is to make sure that there's progress being made I think there is progress being made but at some point you're right if progress isn't being made for the building of these new psych beds then others have to have the opportunity Robin yeah I just want to say on the issue of putting a limit that our mechanism for putting a limit is called the certificate of need process so I don't think we can do that through the hospital budget process so I just want to be clear that I think that's a legal overreach well I think I was talking about through the certificate of need progress process because basically we don't want to approve something that is going to triple the cost of psychiatric care in the state of Vermont and to think that a redesign of other things is going to ultimately factor into successful rate negotiations for the psych beds I don't think that's fair I think that's why you need to have that clear accounting on the psych beds versus the rest of the project because another goal that we have is not to drive up costs of care in the state of Vermont so in between a rock and a hard place here other members Dale I'll have a question so now accepting the design as is and that we have an aging population my question would then be have you communicated with Green Mountain Transit about how you're going to get the traffic flow are you going to have a bus that goes around there for those people that can't walk this campus is it a bus that would go like every 15 minutes the parking spots that would be for the elderly or disabled the key issue we're finding going forward I hear there's a lot is you can make them accessible parking spots but can you to enforce so that other people don't use them other than the ones that actually need them that's my question yes we have security the controls the parking lot now and we can of course access to the handicapped spaces as far as kind of the transit solution we need to and we were pretty early in this concept and we're showing just kind of sharing this is where we are now we need to come up within the next iteration that is something that is a multiple project and so we have been thinking about how you transit the campus but we haven't had the next level of conversations that really happens in the next phase we would have gone into if this phase was something we felt that really would be forward to so it's yet to be discussed I do want to fall for one thing the numbers in in listening to as people quote members we have to be very careful with the difference between construction cost and project cost well we're sharing with you a total project cost the numbers I'm hearing are really about construction cost and so just make sure we're talking apples to apples that's a program I know a lot of it does we're volunteer drivers for people that say for example you're going in for a full-on hospital drive yourself and you can't just get on all the transportation so there's a system in place and I think it's driving the block or whatever it's called but anyways the center will want to have a similar type of program we do and we also work very closely with the Green Mountain Transportation to ensure that the bus patterns are appropriate for supporting not only our kid care setting but all our practices that are geographically dispersed but we do also have a volunteer program that supports people and that usually happens with at the time of service we support getting to the main campus or if they need support we're going to practice we'll work with individuals one-on-one we also have a nice partnership as I mentioned before Washington County mental health we've partnered with them their team and case managers to support patients in being able to attend appointments and sometimes that's a barrier itself of just going to an appointment so we've got a lot of creative ways in which we try to make sure that patients and families can access the care both on the care campus and in our practices Other members of the moment Seeing none we'll let you get back to try to figure out some of the things okay for me to start so we're returning after last week's presentation of our proposal for the 2021 standard plan design in terms of what I want to address today was a brief look at the individual and small group enrollment numbers this is data that as it relates to the plan designs could be an informed piece there were several other follow-up questions that we were prepared to address in terms of timing I thought we were scheduled for about an hour but I should go faster and aim for like 30 minutes or would it be the right amount of time to give out the information we're not kind of rushing just wanted to ask about that in case so I'll start with this and then I'll get over to me individual side first so a little bit of orientation here this is I'm starting with the individual market this is a combination of those individual market enrollees through from on health connect and those will directly through the issuers and it's de-identified so it's illustrating where the population is enrolled but it's not saying which which health plan and they're bucketized into types of plans so I only just make sure everyone's aware on the vertical here is the metal level itself and then across here is the kind of planned type so that that's how we look at 2019 January versus I'm missing okay just have it the January 2020 figures also want to make sure it's understood that these NA cells refer to it just isn't the plan type in that category it's not that nobody chose that plan for example the platinum plan only has a standard level there are no other forms of the platinum plan so the sort ones are going to understand that and then coming soon in a week or two will be a deeper dive into the numbers here that accompany the covered map includes the integration of Medicaid and some more kind of story behind the members here so overall this is the total for January 19 versus January 2020 individual side involved in this by these numbers down about 400 this expresses the same time period in terms of the percent distribution there are no enormous differences here in terms of where the error where the population has a world this kind of a heat map I think is most important this is January 2020 but it's illustrating that but where the enrollment changes have taken place so I think what we're seeing is this January there's a decrease in silver again we're continuing with silver loading so I think what we're seeing because there's some increase in gold and more significantly in bronze there's a decrease in silver that can be attributed to people taking their higher subsidies and buying up for gold for richer plan or down to bronze with premium higher amount of premium subsidy and as I said the enrollment on the individual side is down about 400 around a 1% decrease so moving on to the small group again this is all all of this population is enrolled directly through issuers so these numbers are provided to from the issuers and combined for the same the same categories so from January 2019 to January 2020 excuse me it's up approximately 1900 on the small group side again to look at the kind of changed heat maps again we're seeing a modest increase in the bronze side slight decrease for platinum most of the increases for gold where the small businesses are moving there and then this red is the movement out of the no CSR silver because of the exchange through the small business side we want to encourage all of them to be in the reflective there are a few stragglers still in there from last year to enforce the small business populations of change we strongly encourage that much less than last year that's where we're seeing that decrease in silver with no CSR so that's a quick overview of the two market segments to the extent that it's helpful as we consider the plan designs I just wanted to provide those these talking points and there is more to come in the next week or two okay Dan is going to ask you a question it's written on this so I just want to make sure that I'm looking at the page on page 3 under individual enrollment individuals by metal level plant type and then I'm looking at the bronze without Rx maximum out of pocket and then kind of following that across to the 685 covered lives those would be on page page 3 on the first slide you have up there yep so you see that 685 or 86 covered lives under January 2020 so as I'm looking at the plan changes that the board is being asked to agree to it's in that plan the bronze without Rx limit and so is it the effect projected effect on the changes we're being asked to approve relate directly to those 685 aged lives you're talking about the shift of enrollment from here to here yes I mean that's the way to look at it because I understand this is a standard it's not a non-standard plan so I'm just assuming that the decision we make today will have some impact on the 685 lives understanding deductible for the bronze without Rx out of pocket, maximum out of pocket is that true? yes and are all of those covered lives below 400% of poverty? no, not necessarily thanks I just have one question on the last page on the small group involvement is there any correlation that can be made with the total change in lives which were 1879 and the role plan went up by 1900 and it is possible a company with a small business could have looked at just really pushing people into the role plan somehow or just coincidence so there's 1900 more in the goal and about 1900 more in total and I wondered if it was just an option of what individual small groups are going to present I think we have to look back and appeal back to the actual numbers from each issuer to give that story I think it's a little bit surprising because subsidy doesn't play a factor in this population and I think we would expect maybe more in the silver category where they can buy the reflective silver so I think I was just looking at the total change the total increase such a big increase in the goal I think this plan the high deductible health plan is very popular so I think this is the a lot of that and so I think that's a particularly popular plan where the employer can perhaps subsidize the deductible amounts and so it gives them that option I think we need more detail behind those the way it was formulated because without that there's not a lot of change elsewhere, a small amount of production in the silver I think thanks other members of the board okay moving on to one other piece we're asked to follow up on was a report on the volume of the usage of the plan comparison tool so in broad numbers the usage of that during last year's open enrollment period which was 11-1 through 12-15-2018 was a little over 33,000 page views and then in the same time period for this year 11-1, 2019 to 12-15, 2019 for the 2020 open enrollment there were 23,000 page views so it's about 10,000 less still a robust number and I attribute that simply there may be more factors but I would attribute that to last year being the first year for reflective and silver loading and so we were just as we are this year but last year was a real emphasis on looking at that, using that tool to choose wisely and see what would work best for you based on your usage and budget so I think you would agree that we think the issue would be more because there is such a price hike but you're right last year with the reflective silver there's a big change in me do you have that? I think we'll try to figure that out and then I know we were asked that as the coordinator of the state group I was asked to look at the VBID concept and follow that through we absolutely will for next year watch the public comment period and where that lands and I want the question answered around what would the effect be on standard plans if it's still considered an optional factor for issuers how will that effect standard plans if they respond differently so we'll absolutely take that into consideration for next year so if it's alright I'll move it along to hand over to Brittany Phillips from Whitney Consulting and then ask you to look at the document that was handed around because there are five questions there just addressing it this way instead of by presentation so take it away Brittany with the additional five questions so as Dina mentioned we've got a handful of questions here that we needed to take back and review and research a little bit so we're going to skip around a little bit in terms of the context that we're looking at questions we have laid out and deductible in front of you feel free to stop me if you have any questions that I'm going through so the first question was on the average cost of the specialist office visit based on the information provided in the federal actuary about your calculator this came up in context with the bronze plan without the pharmacy maximum out of pocket limit and so is approximately 179.61 continuous tables so the context with the bronze plan without the pharmacy limit and the expanded demand range so on the bronze plan without the limit PCB officers are not less than that 50% reasonability check this plan qualifies for that expanded range he co-pays relatives in Vermont so in that handout includes information on benefits and cost-sharing plans on the federally facilitated exchanges that rely on a platform in the state partnership exchanges for the last couple years so I think the most recent information is the 2018 plan year but some states do post that separately it's just in a different location and not on the same website but there's a lot of information in the these are offered for 2020 on the federally facilitated exchanges so we also took a look at what the ranges look like for the theater plans in states that have theater plan designs there's about 6 states that have those and so the table between 20 and $30 silver between 30 and $50 excuse me and bronze has the largest variance that we just looked at all these plans that we just looked at those for what theater plan designs are within the range there's some at the platinum and gold level a couple states that we're seeing in other plans as well okay great so moving to the pocket maximum it was noted that the medical auto pocket maximum has increased significantly more there's a pharmacy auto pocket maximum and also increases more on the bronze land versus the other metal level so we briefly looked through this during last week's call but around it since we have those specifics now the pharmacy auto pocket maximum is limited to the minimal, minimum deductible for HHT per Vermont regulations and so that minimum deductible is determined each year by the IRS so over the years since 2014 that deductible minimum deductible has only increased $150 or a little under 2% per year from 2014 to 2020 whereas the allowable auto pocket maximum for the medical pharmacy combined which is released by the notice of benefit and treatment parameters each year has increased $1,800 or a little over 4% per year during that same time period so particularly on the bronze land where the pharmacy auto pocket maximum is already at that minimum deductible limit and is at the highest amount 18 go that really kind of limits the changes that we can make to the fully designed year over year to account for that and so because we're limited on the pharmacy auto pocket maximum often times it requires larger increases on the medical deductible in order to meet the minimum ranges in the AP so additionally the medicine auto pocket maximum has generally increased faster on bronze lands compared to other level due to the emerging impact of the deductible and auto pocket maximum and what I hear the deductible and auto pocket maximums are already you know as of 2014 we're quite a bit higher than say the platinum plan there's an expectation that fewer members will actually hit those deductibles and auto pocket maximums and so they're increased to the deductible and auto pocket maximum um on the bronze increase on the older platinum plans would have a larger reduction in the AP um so it's kind of those two concepts of why we see the difference in trends between the metal levels and also between the medical pharmacy limits are there any questions there? don't think so great we were also asked for some more detail on the formula and process used to determine the increase in the metal auto pocket maximum each year so for 2021 in the draft payment notice there's a $400 increase based on a premium from 2014 so the 2014 limit was multiplied by this premium adjustment percentage to get the new for the current year and that premium adjustment percentage is for capital premium for health insurance from the preceding calendar year compared to 2013 so for 2021 the percentage is calculated by comparing the 2020 average per capita premium to the 2013 average per capita premium and that difference is the increases are determined each year um so I did want to note here that this formula changed a little bit in the 2020 plan here um prior to 2020 uh that percentage was only the change in employer sponsored premium zero per year money the formula now gets insurance premium so it does include the individual market as well the small group exchange market um in determining both the premium increases can I answer this faster to follow up? so Brittany this is Robin um so by including I mean it logically makes sense to base it on both employer and individual market premiums um since the the AB calculator applies to both but won't that mean that that will result in a bigger increase because typically individual markets have higher increases in small groups nationally or am I making too many assumptions? I think it's a little tough to base and we only have a couple years of what you're into um the change in 2020 and 2021 the small market premium um it has increased so about $250 per year and how much that that out of pocket maximum limit is going up each year since um the individual market was starting to be included and they didn't mention that the reason it wasn't included or originally um is because of just the volatility that he sends for you know with the ACA and everything there was a lot of volatility and premiums year over year for the first few years um and so 25 and up nationally um going forward thank you yeah a little bit more I think we can go on to number 5 alright great yeah so the other came up was creating a state for specific um actuarial value calculator provides more information that should be taken into account when considering this um going forward so the calculator the calculator to be specific for their state and their experience um however you cannot alter the logic or the methodology of the calculator so really all that you're doing is updating the underlying data um to try to better match your market essentially um there are one of our policy analysts today the exchange market um not to say that it is possible um to do a state specific with additional data sources that just may not be seen solely on the exchange population it may not be possible if I could have given the exchange population yeah yeah so the I mean the primary benefits of creating a Vermont specific calculator would be that you know the data could be more aligned to actual experience Vermont and those actual about costs um as well as the bucketing between um you know the different service categories um and plans could be better aligned um and we've worked with uh the nature's data before so um that is potentially a viable source um for the data that's already out there and kind of readily accessible um the other kind of on the flip side though some of the cons are again the effort involves whether it's cost effective um there's potential disruption in the plan design primarily in the first year of implementation so um using this national data and switching to Vermont specific data could result in some drastic changes in APs in that first year um that the plan will then need to compensate for in the plan design um of those plans so there's a movement that could happen there in that first year actually change that makes sense for the plan design um so I just like a high level comparison of Vermont's a lot of costs in total and by the different warranted um and we're here to understand how the tax code has changed to be before you know really going down this path um so just in general in Vermont's much bigger uh we would recommend stepping um with CMS uh there may be additional flexibility beyond those that are um ADC um or requirements that have changed possibly in the future release so so at this point I'd like to switch back all right we're going to um Abigail can we get at the presentation from last week I want to review the um some question around the chiropractic and PT co-payment uh Abigail is doing that my assumption is that there hasn't been any legislative movement yet on the bill do we know um nothing I'm aware of that is correct with the Vermont Chiropractic Association the bill was reviewed today and it called them out there um but it was not there was no decision I would say that um they did decide to put PT into the chiropractic bill and put PT so I'm on slide 16 Brittany I just want to point out where we misstated here in the first bullet on both sides in fact the you know as it stands the requirement is for those co-payments for bronze and silver plans to be in the range of 125 to 150 currently for the 2020 year they are at the um set at the 125 limit 125 level rounded upward to the nearest $5 improvement and I'll show you um where that plays out so I apologize for that misstatement here um okay so here we are Brittany now on slide 26 um the PCP office visit at $35 the um for 2020 the chiropractic and PT co-payment is at $45 125 puts it at a place somewhere around $43 of change so we rounded it up to this 45 um and we propose bringing it to 40 anticipating implementation of this um new legislation and again wanting to do a considerable discussion among stakeholders about for co-payments like this to keep at a $5 increment we thought was important um and like I said it is awkward for some of these plans depending on where the um primary care office visit cost is at a 125 level typically can bring it to an awkward spot so for this plan and for this one the same thing where the primary care office visit is at 35 was in 2020 not proposing any change to that but again the proposed $40 we feel strongly it would be good to do that for um to keep with a $5 increment not to be in a position where we had to if we left the co-payment at $45 and then found out later in the spring or summer that that needed to change at that point it's difficult and awkward operationally to need to go back to change those plans let me just point out to you that for the other bronze plan where the primary care office visit is at $40 the chiropractic and physical therapy co-payment fits neatly at 125% already so Brittany anything you wanted to add there on this piece? Change on the silver and the bronze plan with the pharmacy's limit going from a $45 count of $40 premium impact so it would be impact there and that's on my 18 and the estimated premium would fit change so just to confirm my so if the bill passes with the plan designs as proposed with the reduction in those co-pays then the plan designs would be compliant if the bill does not pass then the lower co-pay would be non-compliant with state law because it would be under 125 okay so if the bill doesn't pass and the $40 is non-compliant would you then keep it at the current co-pay is that really what you're thinking? yes I'm thinking it was more likely that it would pass sure proposing it this way makes it most likely to that makes sense since I'm assuming I'm the one who's doing the motion I need to make sure I understand but I think it should also I think people assume correctly and again just trying to anticipate and avoid that situation of having to change that co-payment at an awkward time for the insurers on the exchange so those are the things we get prepared for today so probably questions from the board Tom so Dan I'm just kind of curious about what you think throughout page 35 so that would be a fine one the very bottom line versus estimated premium impact and under the 2021 recommendation design it's three tenths of one percent and the alternative design is one tenth one percent what is the math about that I talked a little bit to Mike today about that and we just weren't sure but the thought was that that is the incremental impact on the premium of just these changes in plan design independent of any healthcare trend pharmacy trend etc correct I think I'll ask Brittany to provide more background but then we did address that on an earlier slide it's a model built by Wakely and it's very different understanding we want to be right in front of it than the modeling that each issuer will use for pricing but its value is it gives us as a stakeholder group a sense of the kind of directional impact on premium based on some good assumptions you know it was a smaller or larger premium impact to make a certain change and you know it's depending on you know some discomfort with raising that specialist office visit beyond $100 that's why I think it landed in the alternative recommendation on this particular plan design but by doing that that one has that impact to bring anticipated impact but Brittany can you provide more background around the math in that model and the morbidity of the market or you know if an issuer goes through provider contract it's going to influence the final premiums of these plans in 2021 we're really just trying to focus on the plan design impact and isolate that piece so as Tina mentioned that premium impact underlines the federal that's really just the differences in utilization and cost of services one checkpoint of what the potential plan design changes are worth in terms of premium and then the estimated premium impact again using lately's model it's another data point to try and kind of quantify those differences so the difference between the recommended and the alternative plan design to the point 3% premium impact on the recommended 0.1% premium impact on the alternative kind of a $10 increase in the specialist office is worth more in terms of the AB change than the $5 increase on the generic so it actually is a little bit you can see it's a little bit opposite of what the ABC shows whereas the change in AB from the ABC is actually design versus the recommended and it's really just driven by those differences in the underlying data between the Q model just a couple of other questions I'm looking at the the bronze deductive plan without the pharmaceutical limit and I'm looking at the increase in medical deductible and that is a 6.3% increase that's just kind of the math and then I kind of keep that in mind I plug in the 2019 premiums for Blue Cross Blue Shield for this plan which is $1,120 and per month and multiply by 12 and you get $13,450 and the you know 400% of poverty level that level that is the premium cliff for a couple of two is $68,960 and so I'm not looking for a long discussion here but I'm just wondering if Diva at some point you know you know I I just think this cliff is just such a steep cliff for some people that are middle class promoters maybe at an age where they're trying to get through college or save a retirement and I'm just and the study that you folks had done by way we showed that for $2.2 million on an annualized basis $1.1 million in 2021 it's only a half a year the overlap of fiscal year and calendar year are you dead set against a proposal that that would expand the premium assistance program to those over 400% to 500% absolutely here to concern around affordability and you know that based on our conversation on affordability last week as well Eddie Stremelow will bring that back for more discussion with Diva leadership but it's just not it's about his favorite to be there I know but he might know something and finally my last one is on the benchmark plan for 2022 are you opening that benchmark plan to which hasn't been looked at I think since 2012 or 2013 to get it aligned with the you know as we go around on the non-standard plans to get it aligned with the all-payer model or healthcare goals more appropriately was you maybe aware that we convened a group to look at the process to more frequently review the benchmark plan consider other alternatives so that is ongoing to get you know a better more repeatable and dependable process but I can say that the CMS deadline for which would require CMS approval for 2022 is coming up soon in May so it's much more likely that the soonest would be 2023 to get to be thoughtful about that consider all kinds of factors and things to build into a new benchmark plan would be you know it's a complicated process so absolutely open to looking at it but hard to say exactly when right time to jump will be well I mean I appreciate that but I've also seen you know for example when the Green decision passed on February 15th whatever year it was 1994-95 that Act 60 happened through the legislature by June of that year so it definitely can be fast sometimes and it just seems to me that the fact that we might be revisiting the benchmark plan after the current all fair mild agreement is finalized it just seems to me a missed opportunity the board no I just have a motion when you're ready you want to make it before we take public comment sure what I was thinking of doing was maybe having two different motions one specific to the chiropractic and physical therapy and then the second on the overall recommendations it just seemed easier does that sound okay to you Kevin it does and I think that I'd like to be careful without knowing what your motion is going to be to make sure that we're obviously within the statutory boundaries yes of course okay so then my first motion is going to be that we approve a chiropractic and physical therapy co-payment at 125% the primary care co-payment rounded up to the next $5 increment in compliance with current law but also conditionally approve a co-pay at 125% rounded down to the next $5 increment should the legislature modify the statute to require the campaign to be under 125% so that should cover us in current law and contemplative change does that give you enough time Dana basically gives you the discretion to go with whatever ends up being the current law I think if the wheels will move forward for great design and implementation of benefits so that if it gets into May, June kind of timeframe it does become more operationally difficult to co-payment and the thought was that it's more likely to roll go through than it won't which is why we ended with that proposal but I got to get one of those crystal balls I have to know that's happening I'm not sure Mike are you comfortable with that? I might also be comfortable with the alternative of approving the plan that designed the co-pays that they've recommended and as long as it's consistent with state law which would give them the discretion to if the bill does not pass to keep the co-pays where they currently are which is because of the range I don't think one of those works it might be simpler to do what Mike said so maybe I'll withdraw and I'll withdraw and then so I move we approve the sorry I move we approve the chiropractic and physical therapy co-payments as presented as long as state law permits those co-pays to be under 125% of the crack-free care co-pay for the 2020 plan here is there a second? second I guess by doing the two motions we almost need to have two periods of but that's okay would anyone from the public wish to make a statement at this time? Dale I'm going back and have her check these hearing aids my comment refers to the plans because you made a motion but I'm commenting on the plans without a kite so the bronze plan well let me start with this I know four people that the last time the open enrollment came up they went from silver to bronze and the reason I found very striking they were looking specifically at what the premium payment was how that would calculate into how much they make a month take that out and how much did they have to live on that was the decision it was that simple they needed to have a certain amount to live on four different people all had the same story with different circumstances but it still had the same theme to it there was no consideration whatsoever about what it really was going to cost to use a high deductible plan and two of those people ended up using it thankfully nothing major came up but the $40 payment just to see the doctor sank them that was more money than they had left out of a week's paycheck then you're talking the medicine on top of that so really concerned that what we're looking at in these plans and the way this is trended the bronze plan is the plan of failure that's how you make failure look good because the people that aren't making that much money are going to end up on plans like this that don't really deliver healthcare that debt should go up because struggling and picking the premium because that's all they can afford we're losing somewhere even if it's not showing up in the hospitals something's not getting paid because the plan was picked over an affordability issue so going forward I'm really really worried and it's not just in healthcare I hear the same theme in daycare can't afford the daycare for the children I'm hearing this theme across the board we have the universal meals plan for children we're talking about starvation and yet we're also talking about healthcare with the same affordability issue here as well those same parents that are trying to figure out how to feed their kids are on the bronze plan I don't know the solution I'm just trying to point out these are things to think about thank you I think maybe it's just easier if I make it now that way no one else is going to comment probably quick question for Dana and is trying to understand what's exactly being measured with the engagement measures with the plan comparison tool so it's page views is that page views of the page where you're entering in your household composition and if you want it to up cities or is it measuring pages of when that's completed and you click the button and you get the ranked list do you know information that I received from the analyst was too high level to really answer that I think it's really just listed as page views and the time on the page is also measured and that was about the same last year and this year so you know the whole purpose of that tool is to not just look at premium but to get a lot of information about the individual's expected utilization so I think that's what's happening in the two minutes I think that's that because the online somewhere pages that click through to get to that list is really you know at least it's obvious that it's really where the meat and potatoes is it doesn't really matter if you get to that first page where it's applicable household composition and you know your income if you want to look at PTC but it's do you enter that and then click to get the list and then even you know I mean looking at a game you can probably track when you're at that list you know I'll sometimes go oh what is this plan doing look at the plan design and that so I think we're looking at engagement on the the plan comparison tool it's really about more than just do you hit that initial page but we really should be interested in how folks are moving through the process and is that process easy to understand because I think you guys have a great it's a great tool and you know focusing on how we can optimize movement within it to benefit the computer consumer would be really helpful thank you thanks Eric anyone else if not we'll vote on the motion was did the seconder agree to the revised motion yes okay great all those in favor signify by saying aye any opposed do you have a second motion Robin I do I move that we approve the plan design changes as described on slide 18 is there a second second is there a discussion I would just make a comment that I think every year this process is technical and frustrating because there are so many constraints around value and really what we're doing here very technical review was a more meaningful review at the very beginning when the board was deciding things about how much should be what types of co-pays for example should be provided for the first dollar or no dollar and all those sorts of value based plan design issues and to Dale's point you know I don't think any one of us are comfortable with the co-pay or deductible levels for the bronze plans because they are I people are spending a lot of money and that's very difficult and expensive to use so I just wanted to say that out loud but at the same time we have a very technical role in this particular regulatory process and so I think we have to live within our statutory parameters other discussion can I ask the clarifying question so the changes on slide 18 not all of them require approval the ones that do are specifically set out here in highlighted agreement so with the motion to be to approve those changes requiring more approval of our policy I'm happy to to amend the motion to reflect that if that's preferred way to do it okay with the seconder okay all those in favor signify by saying aye any opposed thank you very much I'll separate thank you thank you Brittany thank you at this time is there any old business coming through the board seeing none is there a new business coming forward seeing none is there a motion to adjourn so moved we've moved and seconded to adjourn all those in favor signify by saying aye any opposed thank you everyone have a great rest of the day