 It's one o'clock so I'll call to order the Green Mountain Care Board's meeting of May 17th 2023. We have a pretty full agenda today. We'll be looking at the vital fiscal year 24 budget, which will be presented I presume by Ms. Beth Anderson and Maureen Gilbert. We will also be looking at a request from the Vermont Association of Hospitals and Health Systems relating to reconsideration of the fiscal year 24 hospital budget guidance. And then we'll have a staff presentation and potentially a vote relating to one care of Vermont's revised fiscal year 23 budget. First I'll turn it to our Executive Director, Susan Barrett, for her report. Thank you Chair Foster. I wanted to announce that we are going on the road. The Green Mountain Care Board is going out to Morrisville, Vermont, and of course Vermont on June 7th. And we're going to conduct our board meeting in person at the Green Mountain Support Services in Morrisville. In the morning the board members will separate out and meet with different clinicians and organizations and businesses and learn more about the healthcare landscape in Morrisville. Information is on our website and we'll continue to update that under what's new. And if folks are in the area or want to take a little road trip with us, we'd love to see you in Morrisville. I do need to read a reek review decision that the board made. So I'm going to transition to that next and let everyone know that on May 11th, 2023, the board issued its decision and order approving modifications to the Blue Cross Blue Shield of Vermont large group rate filing. The decision and order are posted on the Green Mountain Care Board website, on the what's new page, and on the filing page on our rate review website. For context per our statute, we must announce those decisions when they're made for context for all of you. And in terms of public comments, we are opening a public comment period today for the vital budget and that will be open until May 29th. We have an ongoing open public comment for the one care of Vermont's FY23 revised budget. And that is open until May 24th. And certainly last but not least is the potential next all pair model agreement, public comment portal, where we're requesting any comments that the public has regarding a next potential model with the federal government. We share any of those comments with the Agency of Human Services. It's in the governor's office as they are leading those negotiations and the implementation of that model. Any information regarding these public comments, the items that I've just listed, materials are located on our website. So I'd encourage you to check those out. And with that, I will turn it back to you, Mr. Chair. Thank you very much. We'll take up the meeting minutes from May 5th, 2023. Is there a motion to approve the minutes from May 5th? So moved. Is there a second? Second. Any board discussion? All those in favor, say aye. Aye. Aye. And the minutes are unanimously approved. And I'll turn to our first agenda item, the vital budget, and I'll turn it over to, I believe, you, Ms. Anderson. Thank you. How are you? Please go ahead and introduce yourselves. And thanks for being here. Thank you for having us. I will, if you don't mind, take a minute to introduce the team both so you know who's talking, but also we do have a new team member that I want you to know about. So I'm Beth Anderson. I am the CEO at Vital. And I'll quickly go around. We have Maureen Gilbert, who is our Director of Client Engagement. We have Christina Chokat, who's our Director of Operations. We have Sufrit, who's our Director of Technology. Our new team member, our new CFO is Cara Kalanan. So she is a child by fire. She's been with us for about a month now and joined in completing a budget in this presentation. So we want to welcome her. We're excited to have her on. And here for his, for real this time, last budget presentation is Bob Turnow, who is, I'll pull this budget together, but will be formally retiring in the coming weeks. So I want to, I think you'll hear from much of the team during the presentation today. So with that today, we'll give a quick overview of kind of a summary of our fiscal year 23, which ends June 30th and what that kind of activities and budget. We'll talk through in a bit of detail about what our proposed budget for 24 is, what the state contract and support of that looks like. The team will do a little bit of program highlights and some of our key initiatives and we'll present the quarterly metrics that we traditionally present. Then after that, I do have a quick couple of slides on a proposed amendment to this, the Vermont HIE strategic plan that you approved in December, a slight change to that plan as well, which we'll go through. So I'm sorry you'll hear a lot from me today. Well, Maureen, if you don't mind throwing up the slides, thank you. So to start off maybe on slide three, just a reminder for everyone about how our work is kind of grounded and oriented and it's really in the four goals that are set out. Maureen, if you don't mind going to slide three please. The four goals laid out in the state's HIE strategic plan, which is defined by the HIE Steering Committee in partnership with the Agency for Human Services and also in vital strategic directions. Those are internal strategic goals that we have that in alignment with the plan and the work that we do. The work we'll discuss today both that it's completing for 23 but also that is contemplated for FY 24 that starts on July 1st, earlier grounded in both the goals of that strategic plan but also the deliverables and work that was contemplated in the plan that was reviewed earlier this year. So just moving forward to 23 just to give a sense of what some of the accomplishments we either will have completed or will complete by the end of the fiscal year on June 30. Maureen, slide five please. I'm not going to read the entire list to you but I'll just go over some of the highlights. We have one that we're really excited about is we have piloted through a partnership with VDH making immunization data available to providers at the point of care through their EHRs by allowing them to query the immunization registry directly. You'll hear more about that project later but that's been pretty exciting for us but really for the healthcare organizations who are going to be impacted by that access to the data really at their fingertips in a new way. We've made a lot of progress and work to integrate new data types in the HIE in particular we're working with the designated agencies across the state to start to integrate part two data and that is been a really exciting project for us as you know that data is protected by more than the traditional HIPAA guidelines but also by 42 CFR part two. Really the way we're phasing this project in is first really taking the data in and not making it available externally but making sure we can get it in and protect it in a way that it needs to be kind of protected and tagged with a goal that as the new form of 42 CFR part two which is out in a draft form now and expected to be finalized by the end of the calendar year is in place we'll be able to put the appropriate controls in place to share that data as appropriate under the new rules and kind of integrate that with the healthcare data that we have for a more complete patient record so we're excited to do some of that work and that planning there. We've started work around designing and thinking about making APIs available or application programming interfaces which will be new ways for accessing the data in the HIE that should make it more accessible to a larger audience of the appropriate individuals to have access to it but to get the data more accessible into apps in places where people want to see the data. Sue will spend a little time later in the presentation giving you just a little foundation on what APIs are because it's something you'll hear us talking about in future presentations and it'll be a lot of the work that we'll be doing over the next year is to make those accessible. Other work has been with the Department of Health really looking at some HIE data that we have and how robust the data we have on race, ethnicity and language and sexual orientation and gender identity are really this year has been evaluation work to understand what we have what we're receiving how consistent it is to then work with Department of Health and likely healthcare organizations about making sure that we have consistent and robust and complete data to help then inform some of the public health uses of the data but also hopefully then to have more robust data for other purposes too to understand health equity across different populations. We've upgraded our platform we've continued to build new interfaces to get data into the HIE and we've transitioned our security program to a more rigorous standard so that doesn't change our security practices we have very robust security practices but puts more rigor and formality around some of our program and planning. So going to the next slide just to give you a sense of how this turns out for end of year financially is we do expect to perform higher than budget for the year so to end up with more of a surplus than we intended on this was due to timing on projects and when we're recognizing some revenue we're pushed off some projects because some were made a priority earlier in the year so it's transitioned when some of our revenues come in and when some of our expenses actually occur in the year but as we'll get to a few slides later we would like to ask to reinvest those monies into a project that is pretty critical to our work and we're excited to have the monies be able to do some of that. So then moving to fiscal year 24 so really what I'll start with is giving you some context on the contract that we have on the draft contract we have in place with Department of Vermont Health Access it is with CMS for consideration that will drive the budget for the year. So starting with the next slide just some context that I think is helpful when thinking about our budget you're used to seeing our budget done on a fiscal year basis which is July 1 through June 30 for each year but doing a contract with EVA for a calendar year which was January through December this is the first year that we're actually changing we because it aligns both with the state and vital fiscal year we've been able to change the contract to actually align with the fiscal year instead of calendar year so we've actually completed an FY 24 budget that is based on a contract that is while still draft because it's with CMS for their final review and approval is a complete year budget so less of that you're used to us coming with an amendment mid-year because we didn't know what the second half of the year for sure was going to look like there's a little more certainty in the budget here we hope. And what the contract we expect will look like for this year is total potential for almost 11.3 million in revenue but what you'll see represented in the budget that I'm presenting is really about 9.4 million in revenue there's an additional almost 2 million in projects that are less clear about the real scope and timing of what the goal is but there is the potential for demand for additional projects which I'll talk about in a minute so we haven't included those projects in the budget that's being presented because it would be really hard to put in some cases to really understand the cost because we don't have clear requirements or understand if the need for it will happen in this year or potentially future so the contract in the budget will have different amounts and going to the next slide gives you a sense of the projects that are actually included in the budgeted numbers for our development work so you're used to our contracts they contain both a component that is for what we call M&O made into operations which is the cost to operate the HIE license the platform that the HIE operates on the MPI tools and the integration engine all of those pieces and then to provide the kind of support that we need to provide to the healthcare organizations in getting the data in making sure the data is flowing get new people on boarded to using the tools and training about how to use the tools and then we have what's called the DDI project the development design and implementation work and those are the projects to build new capabilities and functionality and so there's about 3.2 million dollars in the contract for FY24 for that work and that includes things like creating APIs which as I mentioned earlier will be making data and the HIE more accessible to providers and healthcare organizations also potentially using to collect data into the HIE in different ways will continue to build interfaces to get more and new data into the HIE in addition to the traditional providers or what I'll term is traditional providers that we've worked with the state is also I'm sure you you've heard in these conversations and in others implementing what they're calling the MDAP program the Medicaid data access and access aggregation and accessibility project which is really seeking to enable more providers who maybe weren't eligible for some of the funding programs through the state or CMS in the past to get access to health information technology so to get EHRs and tools in their practices and operations to support their work and then to be able to connect to the HIE so we're hoping to be able to connect them of those organizations who might not have been able to take advantage of participating in HIE in the past engaged in our work. We'll be doing some work with the Medicaid agency and AHS to support some of their initiatives and and needs internally for access to data we are going to continue the work that I mentioned about integrating healthcare organizations to the immunization registry right from their EHR so we've piloted with one organization the goal is to work with many more organizations throughout the next year to get them that capability. We're going to work with the VDH to get more lab reporting in so one thing we learned through the pandemic is we do get information about the the test results that are happening at organizations both the hospitals and commercial laboratories are across the state and we've been delivering that data for COVID results but they have a lot of diseases that are required to be reported and our goal is to try to collect more of that data for them so it gets them that data in a more timely manner and also saves healthcare organizations from having to submit the data to multiple entities and locations so hopefully we can streamline some of that reporting. A couple smaller projects with VDH to do one will be a continuation of the race ethnicity and language and the SOGI work that I mentioned earlier. Additional support for that MDAT project there's some supports needed by the organizations that might take advantage of getting health technology specifically around doing some security risk assessments and analysis that our team has performed with other organizations in the past will be will be supporting some of that need going forward. We'll continue our work to get new data types into the HIE and making sure that we can actively secure it so that includes the continuation of the work with the designated agencies to get more of their data in and then secure it and identify the appropriate opportunities to share it out and then also getting some sort of determines of health data in there and working with agency human services for some data from there. Finally we'll be looking at enhancing the provider portal that we have with some medication fill capabilities so that's a way of providers getting information not just on what's been prescribed to a patient but what medications they've actually potentially filled. We can't tell them they've taken them but at least they've gone and purchased the medication and hopefully we can get some of that data out to them. Finally we'll continue work which has been in our contract for a couple of years to work with by state to continue the work that they do for the Monroe Health Association's activities and quality improvement efforts and so that will be in our contract and we will subcontract with by state to perform that work. So then just going to the next slide just to give you a sense of the what the projects are that aren't included in our budget but could potentially become projects during the year. Is there space to do up to 125 additional interfaces for those organizations that are under the MDAT program who are new so the contract itself allows for I think 150 new interfaces to be built and this would allow to expand that number for another 125. That would actually be done through contractors that we would use to do the work not vital staff because we'll be fully focused on the work that I just went through but we do want to leave the potential to get as much data and as many organizations engage as possible. Finally there's some space to potentially do additional work for the Medicaid program and some of their work on their information systems internally and getting data available to them sharing that our patient index so they can do some matching of patient records things like that. That's work that is we don't know timing on that work in actual scope and so that's the reason that that's not included and then there's a task order which is typical in our contracts with AHS for things that might come up during the year at least flexibility to take on a new project or expand scope of the project if and as needed. So moving to the next slide this all rolls up into the budget which I'm sorry I realized it is small here but the 24 budget which is outlined in red which brings us kind of net kind of surplus at the end of the year of $78,000. So what you'll see reflected in here are just kind of I'll go through a couple of slides which break down some of the information so you don't just have to stare at numbers here but moving to the next slide to give you a sense of the revenue sources that are in here in addition to the 6.3 million that we talked about 6.1 of that is the maintenance and operations of supporting the the day-to-day operation of the HIE 3.2 as we just walk through is those those DDI design development implementation projects. We do have deferred revenue for some projects that haven't been completed that we will be completing kind of carrying forward some some revenue kind of accounting activity in there to to support some of the work going into the next year and then the other contracts that we tend to have in place as we do custom reporting and data extracts for one care we do some work with patient ping we have a HISP that some organizations take advantage of and we have included a slight negative allowance for revenue knowing that a number of our contracts are under negotiation now and while we hope they end up where we expect them to end up there is the possibility that we won't continue with some of them or that they will the scope will change and so that's just allowing a little bit of room for knowing that there may be some shifts in that revenue the projected revenues. Next two slides just give a little bit of a sense of some of our bigger expense components right staffing is a significant expense for us it's about 38 percent of our budget and this is staff that work across both the M&O work and the development work the budget for this year does contemplate creating one new position in technology to support some of the new capabilities that we're putting in place it needs some new specific skills that we don't have on the team and then the next slide gives a sense of the software expenses and software really includes purchases of software but a lot of this much more frequently now is licensing of platforms or software so the core HIE platform some of the business operational needs that we have the master patient index results delivery tool and so just to give a sense of the component so looking at the software expenses the gray section on the left is really the core components of the HIE and the cost for those components themselves and then we break down what the orange is really what's associated with project work so the the DDI or the enhancements and then with the business software we have things like project management software and accounting software things like that outside support tries to do a similar breakdown so this is where we use potentially consultants expert subject matter experts we need additional support just to have more hands to get some of the development work done which isn't long-term staffing needs that we have and that breaks down the blue bar here or blue slice here is really the operational and more day-to-day support that we have and that also includes things like legal and accounting work like that and then the the work to support the projects is about two million and that's not just I just I should be clear about how I said that it's not it's not just staffing so some of that may be contract staffing but in addition that will also be if we have consultants helping out like a consulting firm helping us with a project or something like that the next two slides I won't spend a lot of time on because I don't think there's much there but I'm of course always happy to answer questions this just gives a sense of the indirect rate and the consistency so the blue bars are really the indirect costs that we have those are things administrative cost insurance general things to operate the business relative to the overall budget and then the next slide gives a sense of our balance sheet assets which you'll see the right bars the projected for the end of 24 we're projecting decrease in balance sheets assets and that is because we're asking to re-invest some funds into our project which I will talk about just in the next slide so that is our core operational budget for 24 but one additional thing we are hoping to be able to do is take 600 up to 650,000 of surplus that we've had in prior years or a cash balance in in in reality to um to build a cave or to rebuild the capability that is pretty critical to our work and it is a message archive which will really help us complete the transition from our legacy infrastructure to the this new platform we've had envisioned and just for context what the message archive does is really I mean it it does kind of what it sounds like and we get messages consistently from healthcare organizations and these are there ADTs and CCDs the messages that have the healthcare data and them and you've heard us talk about the work that we do we do do a lot of work to improve those messages so we match them so we can say this patient from this organization is also this patient from this organization put that record together into a record we standardize code so where you might use a local code and a practice we standardize it to more nationally accepted code sets so again data can be compared across the organizations well what we do is we maintain a store of the raw raw messages that come in up front and we use that store for a lot of our operational and data quality support really gives us a chance if something goes wrong or looks funky in the system where we get questions to understand you know what's in a patient record we can always go back to the core message and see what the data looked like there was there a problem in the way the data was submitted was there a problem somewhere along the way on our pipeline and it's a it's a functionality that's used pretty pretty frequently for us to make sure that we're maintaining good data quality in the HIE it also does track the changes that have happened to a message so we can see along the way where all the transformations happened also serves as a backup store of data for us though should something happen at our vendor it's you know kind of worst case scenario it's a data backup but it also allows us to replay messages so if we do find that there's an error you know well you know healthcare organization might have a problem in a feed to us we can delete the messages that they sent and replay them through to to make sure we have a good set of data in the HIE and we think you know I think there's more advanced capabilities we can use off of a message archiver in the future but that is kind of at its core why we need it now next slide please Maureen so we want to make this investment because the interest the message archive we have now is built on internal infrastructure that we've had at the HIE you've probably heard in the past the reference is the hdm the health data mart and it's built on old hard it's built on what was new but is now old and end-of-life hardware and software that we really need to replace in part of the the impetus behind the move to the new fire-based medica soft platform over the past couple of years was to replace much of the functionality that existed on that health data mart we did our client reporting off of that platform that's all moving on to the medica soft platform but this message archive is kind of that one of those last components that it was doing we are our original plan thought we could do what's called a lift and shift of that capability from the old hardware on to a cloud-based infrastructure to have the same capabilities but after more kind of planning and evaluation of the state of that infrastructure and then the needs that we have for that in the future for that message archive and how we really want to use it and our day-to-day operations realized it really needs a rebuild rather than just a shift to the cloud which is a more expensive project than we had anticipated and so what we'd like to do is use the 650 000 in surplus that we've had from from our our our work in the past couple of years to build this infrastructural which will allow us to continue to to continue our work on data quality and improving the the the data availability and and accessibility in the hie so that takes us through the budget i'm going to stop for just a moment i sometimes you have sometimes we stop here for questions and sometimes we wait till the end so i just want to check before i just go flying through the rest of the presentation i think it's fine to just continue on um we're pretty well trained to let people go through the whole presentation at this point so that's that's totally fine great thank you well i'm taking us to maybe some more of the fun conversation instead of just the numbers um wanted to just give a little context on um the work at the hie and how some of that is changing for us here in vermont but also kind of on a national level and how hie's are emerging from a traditional model of really just moving health care data pushing 80 t's and basic patient records back and forth between health care organizations and making that available to really becoming what's what's being kind of termed as a data utility or a health data utility as a phrase that's starting to be used on more of a national level around that and it's really a very different um operating model for for traditional hie is really looking at working with new partners so not just health and i don't mean to minimize any of this but not just the health care organizations but the new work with public health working with pairs working around care coordination and really trying to support and inform other efforts in some of the work and i just think it's it's um a good context for us to have as we think about this budget and and the hie plan and some of the work you're going to see for vital for this year but also in future years is really moving us here into this new model of really serving as a health data utility and really serving new stakeholders and more stakeholders across the state um hopefully meeting some new use cases and really doing things here you know we do some things here in vermont that are very different from how hie is our health data utilities and other states work that i think is really interesting and and you know want to just bring some attention to right the way that we really treat our data and focus on the making the data that we get accessible for lots of different purposes the way we you know we we don't just pass messages from health care organizations but we dig into them to pull out data elements that are important to some of the stakeholders who are using the hie data for reporting and extracts in their work within our patient portal to make it really have a like clean front page that you can have a snapshot of a patient is work that doesn't happen on other organizations the partnership that we have with some of the stakeholders particularly the data that we do provide for quality improvement efforts and population health activities across the state is really important to the work that we do um and really just wanted to kind of introduce the model of like what this starts to look like it has health data utility because i think this is language we'll start to see and some of the federal work that's happening you know as cdc is talking about some of their funding and and encouraging department of health to work with their hie and their health data utilities and their work and and and some of the programs that are going to come out of cms are going to start using some of this language so i just wanted to kind of introduce this and kind of give you some contacts for how this aligns with the work we're doing here in vermont and i think as i turn it over to christina to talk about some of the work in the bi-directional interface you'll hear a bit about some of that and how we're working differently with new partners so with that christina do you sure mines thank you not at all so as beth said we have implemented a bi-directional immunization dating data sharing service and we just launched it this uh april between the department of health and uh our first organization northeastern vermont regional hospital uh and that enables the ability for clinicians and staff at nvrh to query for patients comprehensive immunization records get all of that history right from inside their EHR so as you can imagine they get a more complete picture of their patient and a more efficient workflow in the fact that right within their EHR they can get this information it's transparent to them they don't need to sign into a separate system this being the immunization registry and through this effort we have partnered with the department of health in order to to participate in the association of state and tribal health organizations their immunization data exchange advancement and sharing learning community also known as ideas and so it's been a great partnership in that we've been able to through this collaborative share information not only with with asto the collaborative but also to get information back especially as we move on to rolling the service out to other organizations which next slide please so we are moving on to additional hospitals in order to roll this out the federally qualified health centers and other independent practices to enable this to more providers throughout the state we are currently in communication with over nine EHR vendors to roll this out to those organizations and the exciting part of this is that the department of health hasn't stopped with just providing the immunization health history through the service that vital has set up between the organizations and the immunization registry but they're also rolling out this summer the forecasting capability meaning once the provider has the immunization histories they can also query and receive back this is what the patients need to now receive for vaccinations so very exciting work and that work will continue in fiscal year 24 as we partner with the department of health these organizations and learn more about the capabilities of these vendors before I hand it off to Sue regarding the next topic any questions great I'll be happy to answer at the end as well so I think what we wanted to do is spend a little bit of time I'm sure everybody has heard the three letter acronym acronym apis and knows it stands for application programming interface but I think we wanted to spend a little bit of time because it is such a big part of our upcoming year you know making sure everybody understands the specific parts of apis that make them important in our new world because of course we've had programming for a long time so what is it about an api that makes it so special and why do we talk about it in this space so the what's of apis are it's code that enables in our operability so if you're thinking about the the ability of two systems to talk to one another and the pretty basic diagram that I have at the top of this it's it's it's allowed us this application programming interface has allowed us to make connections over the internet between multiple systems whether it's a client-based system trying to connect to a web server in a back-end database or two different systems connected over the internet it is that it is that type of infrastructure that allows us to make those connections and exchange information the way we do it is based on standards so throwing out the buzzwords that you've heard or the buzz acronyms that you've heard of htp htp ds of being able to use the web as its transport mechanism the fact that it's restful and it's using json and xml and in the healthcare industry fire those are all those last four are all standards around how the data is formed and how it's transmitted across the internet with fire being the specific data standard in the healthcare and industry the big piece of it like i said we've had programs forever so what's so important about apis well it's because we moved away from this idea of creating this one big monolithic program to creating what we call microservices and the microservices are smaller pieces of code that can be reusable so i'm thinking of an example of you know if i have an apple watch and i want to send my heart rate to my doctor you know there's a microservice somewhere within this api infrastructure that not only allows me to read data about patients but it also might allow me to write the data and it instead of creating a whole system for that apple watch it's the same api that gets reused over and over again despite what use case or what application is out there whether it's an android or whether it's an apple watch or whether it's a provider at a healthcare facility using some app inside their EHR the same piece of small code could be reused over and over again to provide the interface for that application and get to the data from that application now the whys of this i think i'll turn over to beth you know it goes back to cms and their their drive towards interoperability for healthcare yeah yeah a lot of the i'm going to say mandates just as a broad reaching word um that cms has put out for healthcare organizations for developers of certified health it so those are the people who make things like EHRs um and for and for the federal funded payers so medicaid medicare is to really um make patient data available to the patients and the ways that the patients want and that data includes both their clinical data maybe their claims data um might be provider lists that come from their health plans um to make it accessible to apps that patients might use and so the the goals for these apis at its core is really around patient access and getting that data that they want to kind of help manage and maintain their own care um it's also expanding out to making the data interoperable between healthcare organizations as well so it might allow for us to exchange data with a hospital in vermont or you might allow a hospital in vermont to query the hie specifically for the types of data they want or the subset of patients that they're interested in um and really just allows more accessibility to the data than some of these bigger harder extracts or feeds that we might have built in the past so i think we'll see use of these going forward not just in the patient space but also with the healthcare organizations as well sue are you done should i pass it on i wanted it it's a yeah we i did want to compile a couple of the other um terms just because you'll be hearing this type of terminology which is a little bit heavy and technical um like we talked about before the fire fast healthcare interoperability resources it's just a standard for the way we form the data it helps drive towards consistency because everybody knows they're supposed to put the data in a certain format within certain tags inside of a document so that all computer systems can read them correctly um then we have the smart on fire and oauth 2.0 which is the mechanism that we use to make sure that we have security and and around the um data how people will get authenticated to that information and get access and authorization to the specific levels of information that are appropriate for them then there's the standard of open id connect which we talk about and this is over the top of oauth 2 this is how we actually verify that sufrits is really sufrits um and then grant her access to the system not being sure that she's the right sufrits and then the us cdi which is the united states core data for interoperability another standard that we have around healthcare data for um the types of elements that we're most interested in using thank you great i'm just gonna um talk a little bit now about patient education and not um any real major updates here but just a reminder that vital is committed to ongoing patient education first and foremost in partnership with the organizations that share data with us or who use the health data that vital provides um we do that by giving them a toolkit of education resources that they can use um in their in their portals in their social media um in their notice of privacy practices and so forth brochures um flyers translated into many languages and then additionally we're committed to direct outreach to vermoners and we um had a campaign last year um reaching out to vermoners primarily through um youtube and social channels we are about to launch another campaign early this summer um to reach out directly to vermoners sort of supplementing that that work we do with their providers um and you can plan on seeing sort of continuation of that throughout 2023 so starting with um some social and likely newspaper in june and continuing with some other tactics later in the year we also um is part of this update to the board um do quarterly metrics this is part of the the standard um presentation here so i want to just share a little bit about um how much uh data we're sharing with our partners how much they are accessing it first we will talk about the percentage of vermoners who are opted out of the vermont health information exchange and as expected this rate continues to drop as we get further away from that time when people were um opting in rather than opting out and we get lots more new patient identities incorporated into the health information exchange and fewer people opting out certainly we do see a steady stream of folks um reaching out to us one by one to opt out but it's at a much lower rate than when everybody who shows up at a doctor's office is being asked do you want to be in or do you want to be out this is um measuring queries of vital access our clinical portal by the organization type so you can see how use of that clinical portal is distributed across the organizations um that we offer it to you'll see um just some really interesting distribution here certainly we've got some hospitals using it certainly we've got independent practices relying on it actually an even larger rate than hospitals or larger number than hospitals and then community health centers really strong use as well by federal and state agencies so here the vermont department of health features prominently as does the vermont chronic care initiative the care coordination arm of medicaid and emergency medical services are relying on this tool as well so um lots of different types of organizations using our provider portal this is queries over time so you can see um total volume we're doing about um well this past or the latest reporting month march of 2023 12,669 queries and a query is um measured as an access of a patient's chart up to once per hour or by organization um so um if somebody's going in a couple times within an hour we don't count that if they're going in um uh twice in a day that that does get counted um and certainly we can see some steady growth here over time next is queries of the vermont health information exchange via the e-health exchange um network uh this is on pause right now we are establishing um new connection through the e-health exchange hub e-health exchange does not allow um us to re-establish point-to-point connections we had to reconnect through the hub that technology is in place but um based on the national um to the data sharing environment we are kind of re-entering this carefully and we are planning on re-establishing connections with the university of vermont medical center first um and then the VA and DOD so results delivery this is the service where we deliver lab results radiology reports and transcribed reports directly into the EHR of an ordering provider primary care provider orders a lab test behind the scenes vital delivers that result into their EHR most of the 586 providers who are receiving these results don't even know that vital is is doing this um but there is a large volume of these results delivered every day and every month um in march of 2023 over 100 000 results delivered and then lastly you can see um the types of organizations that really rely on this service and because the results are largely being um calculated or the laboratory tests are happening at a hospital uh typically or an independent lab um it's the federally qualified health centers and independent practices who are ordering those tests and then receiving the results back into their EHRs so real reliance um by those two types of organizations on this service and that's our quarterly metrics and and our update for you so i'm gonna stop sharing um for any questions and certainly we can go back to any slide if there's a particular one you want to focus on i also i'll just ask if you want me to do the hie strategic plan change like now or after questions please what's easiest in your order um yeah we had it set up oh we didn't um why don't we do some questions now because they're kind of different topics it might be easier to break it up a little bit um i'll open up to my fellow board members to to go ahead with any questions or comments they may have um well i'll go first i had a couple quick little easy ones um i think miss anderson you said something about the effort that it takes to translate from local codes to national codes i presume you mean from like laboratories but like lab corps specific codes to like codes that kind of thing is that what you're referring to it could be or it could be code and christine you can christine is gonna laugh at me and want to help so i'll tell her she can um but it could be that there uh an organization has local just within an organization ways of designating um specific data elements um that are you know male female might be am or app and we might change it to male female things like that so it's it's not always a lab code it could be other types of information as well okay okay and what's the scope of that issue is that i'm just trying to get a sense of how much effort is involved in making those translations so they're all in the same language that's interesting christina do you want to yeah i would say most of the effort is understanding what those codes in are that would come in the door through a message so that we can set up a way to map it to a standard code once you set that standard then it's automated from there occasionally there may be a code that makes it through the door that even the organization was unaware that they were documenting sometimes it's think of like a fat finger situation where somebody just entered the wrong code other times it's historical codes that were used over time that now make it through and again we'll catch that work with the organization to determine what that right mapping should be to the right standard and set up the automation for that okay and you guys do that mapping and translation in-house like for example from if you get a bunch of NDCs you then have a mapping process to translate it to rx norm we do we have a way of doing those local codes to the standards and again it's we have sheets that we've perfected over time working with organizations to make sure that we get to the right information very quickly and then automate that translation within our integration engine we also use a third-party terminology service engine that does more of the clinical concept mapping from a local code to a standard Loink snow med you know those types of things and and again once we have that mapping it's automated and we also use some of their already built-in logic where it would know how to already do that mapping right like the walters clor product or something like that that kind of they change monthly right a lot of these it's it's through our partner in main who offers this service it's the main hie they have a product that they use successfully and we use it as well and we do roughly about 20 million insertions of mappings from one code to another code set every month automated obviously there's nobody behind the scenes doing that that's significant yeah it's really significant and we maintain so back to best conversation about the message archive now you can see why it's important to know what came in the door is the raw message when we also enrich the message with the transformation we keep the original as well as the transformed so that we can troubleshoot as is there any opportunity for the for anyone the board or otherwise to minimize those upstream challenges so that we are in a more uniform set of code so you don't have to do that much work it's a really great question I think some of this will come through with the mandates and with the standards that are being rolled out and as more of the vendors and the organizations mature they will send more of the standard codes again sometimes the content may not still match with the expectation of what code should be used simply because of again historical information and frankly the capability of the vendors those who are certified EHR technology we expect to see some improvement over time but also standards change and we might need to map from one standard to another standard in the future think of ICD-9 to ICD-10 that's my short answer slide 21 you talked you spoke about the immunization records and ability of a hospital to to get those from you and I think it was northeastern Vermont Medical Center is that right northeastern Vermont Regional Hospital yes NVRH right and why is it is it just NVRH or can we expand this beyond NVRH or is this that is the plan our first we've been saying pilot but it truly is our first organization that we rolled it out with was NVRH and so learning through them learning through their vendor they do now have that capability and the data comes from the Vermont immunization registry vital is the go between allowing the technical capability from the EHR vendor we check the structure of the message the content to make sure that once it goes into the immunization registry it can very quickly come back because it's got all of the necessary information in it and yes we are already working with several organizations and those nine plus EHR vendors to begin rolling this out to more organizations throughout the fiscal year as well as this summer and is it is there any plans to broaden it beyond immunizations to diagnoses or prescriptions or labs or anything of that nature we do have a project with the Department of Health now where organizations can submit data to the Department of Health I think that there's through this learning collaborative and through a partnership with VDH there is the opportunity to expand beyond what we offer now and and consider that in the future other ways to get more data back into the hands of providers right what I'm sort of envisioning is I go to a hospital and for whatever reason they want to know what it's not my usual hospital and they want to check what my meds are what my family history is to do that now would they be able to I guess it's my first question they'd be able to use the data that we have in the VHI without the public health data so through our provider portal being a really good example of how that would happen they could log into the portal they could look up the patient and see the patient's record that would have in theory depending on what we what's in their record what we've received information about their allergies medications they use conditions things like that we are actively working in different ways to get that data to the hands of providers so so it can be more available in their EHR not in a separate application and that's some of the focus of like this API work that we'll be doing to start to enable some of that this is a rudimentary question so I apologize if it's just really not that exciting the question but why does a hospital or an EMR have to go through an HIE as opposed to directly with another EMR or another hospital I'm gonna give you the short answer we of course could talk about this all day because it's what we do but it's really because we enable that interoperability that doesn't necessarily exist now so we handle the patient matching so we know the MRN from the hospital matches the patient's MRN at the local practice they wouldn't know that necessarily so we and we we don't just know that we have tools that actually allow even if the address was coming and different for that patient but we know some other demographic information that we can match up to put that record together we standardize the code so they you know the local code set that the practice uses if the practice uses M for mail like sure most people can figure out what that means but their system wouldn't necessarily know how to translate it that they're capturing sex with mail instead of M and so that's really where we add the value is the the curing the data to make it more standardized so they can actually ingest it in their systems other pieces I'm sorry I'll stop me where you want to stop me but other pieces are they don't necessarily store the data in the same places or call the elements the same things and so we do a lot of that standardization to say the diagnosis code this is the diagnosis code call it that this is the diagnosis code call it that so it all ends up in the same place and can be used that's really helpful thank you is that a good start okay no great thank you and my last question was on the patient education I think was mentioned around slide 25 a couple questions one what is that education patient education or where does it come from sure so the patient education is designed to help patients understand how their data is being shared with whom for what purposes that is developed by our team at vital in collaboration with with some vendors and communications vendors and then distributed through the participating organizations and then through some direct outreach that that we do typically annually now I see okay it's not like clinical patient education like hey oh and you're 44 you need a colonoscopy soon not that kind of thing no and that's a really interesting question and and it is different than than what we do which is really about the data sharing and awareness of the data sharing right okay okay great thank you I don't have any other questions oh and can I just piggyback on that for a quick second please I'm just wondering thank you so much for the presentation today as always informative um and it's nice to see a surplus so that you'll be able to reinvest that's good news um I guess I just wanted to ask if it's possible in your next you know reporting back to us or you know your next visit with us if you might be able to share some of the samples of of that public education outreach you know whether it's through the social media like you know what what that looked like I'm I'm kind of curious as to how you're explaining how the data is being used and shared with whom and why and my other request was the next time you come in I am also very interested in learning more about the work that you're doing on the social determinants of health uh you know I know that's for implementation in in fiscal year 24 but between now and then I'm sure there's gonna be a lot of progress made on it so maybe a bit of a deeper dive into that because health equity is such an important issue here at the board and so understanding um what the progress on that front will be really helpful so more my comments are more about next time you come in these are things I'd love to hear about in in greater detail if that's okay but fantastic and thank you very much today thank you it's great to know what you want to hear about I'll go ahead and jump in I was wondering and this could also be you know an update it doesn't have to be now but I'd be interested in understanding a little bit better um your how you're supporting blueprint in Vermont chronic care initiative and um where the various end user services are in terms of development like who's using what what you know just a little bit more detail on that component right why don't we um we could rather than to hit some topics today like can we come back with that because I think it might be helpful for us to work with those organizations so because we can give you some context of what we provide but then also why right instead of just so we send them this which might not be helpful to understand the the impacts of the value that works for me if that's if that's cool with the chair perfectly reasonable sure yeah of course but my only comment is it's it's interesting it's it's this this work is clearly a mixture of exciting new technology with these um apis and re-envisioning how healthcare you know health information is going to be structured and used in the future with incredibly like detail the diligent probably tedious information of you know making sure every little thing in this massive database lines up so it's um I imagine at times it's it's very cerebral and engaging of the big process but also like you know clearly um a lot of care and diligence goes into the work um and I think one of the things I I gleamed from the presentations that I've seen from you so far is that really in the current state this is a hugely important resource for FKHCs and independent practices and how they get laboratory data and can can communicate with each other and I think that um but and I think we've had these conversations before that I kind of piggyback a little bit on the Owens interest as you know as a provider you know if say Sheriff Foster came to my emergency department and hadn't been there before or that's not as normal hospital of some way that I could access his information uh in his chart in front of me which I know that that this is sort of a complicated issue of of so many players kind of working together to to get that information to the provider but just to continue to advocate for that stance that I that I think having providers to be able to have access to patients information within the EHR that they are using is sort of my my dream to where this would go and I think many people share that dream I see Christina nodding um quite vigorously there saying things that um but the one other the one question actually I had which is sort of not really even uh health IT related in your in your budget what and we get a we get a lot of public comments um from small businesses uh on the cost of health insurance and the impact of their budget and I saw that you had put that sort of in there but is that I was just wondering if you could comment on the impact of of the cost of ensuring your employees as a line item in your budget over time and and how that has been for you to to manage um that is a great question Bob Bob probably can talk best about history we'll start Bob to put you on the spot but please feel free to um to correct me here like any other provider it you know it increases every year we are on the exchange we we purchase our insurance through the exchange we do provide pretty good I would say actually very robust um health insurance benefits for our staff and their families um and and that's been important um important piece of our our benefits as a nonprofit we think that's a really you know that's that's an area where we feel like it's important to um to focus on um but it's consistently rises every year and we um do a mix of um a higher deductible which we cover for employees right because in the end it actually ends up um a lower cost for us in the full premium typically um but it I would say the past you know the I mean you know you you approve them the premiums are rising you know 10 12 percent each year that comes right to us we our employees um contribute a piece of their premiums but we do cover the the majority of it and it hits vital line Bob would you like to as the numbers guy out going down I just have to um support what Beth has said um certainly during my tenure we've seen it um rise um during that period and as Beth mentioned we've taken a number of tax we uh we have switched underwriters um we have switched plans um to try to keep things um in check but it'll you know ongoing it'll be a challenge thanks thanks for addressing that if I could just piggyback off of this um conversation a little bit the uh in my prior work working in organizations we're working with providers and working with the IT department um from a provider standpoint what we really want in order to be able to better manage our contribution to health care costs is to understand our patients and what I'd really like to know as a primary care provider if I was one was how many patients of mine have diabetes and how many of those have their diabetes is poorly controlled and then of those patients what proportion haven't I seen in the last six months because the guidelines are see them every six months and I know the patients who come less frequency less frequently or it may appear erratic or chaotic those aren't good words to describe what's going on but they get used in health care a lot that those those patients um often have other comorbidities right they may have mental health comorbidities or they're the social determinants of health that Jessica mentioned they may have transportation difficulties um they may have um they may be in and out of the workforce seasonally right they're all kinds of things that can go into that that make it difficult for me to manage which those patients are the ones that end up using the emergency department in unplanned ways or they get admitted to the hospital and if I could better understand their needs I could maybe redesign my interventions and so to have that as a backdrop and then talk with IT folks and we realize that gosh to get that information about people we need to merge a lot of data sets and we need to think about how we're going to store that data and how we're going to design governance around the management of the data and how we're going to analyze it how we're going to get it back to the provider and we can go from one conversation to the next and and at the end of the day the providers still say I just I just want to know how many of my patients have poorly controlled diabetes then we can work through the rest and so um I think I mentioned this in one of the last meetings that we had you have wonderful presentations and you're you're managing your budget really well and the microservices idea that you talked about today really fascinates me the upgrading that you're that you're doing in order to be able to better manage the different data sets all wonderful um but I just encourage you to keep really trying to focus on how do we get that number two clinicians what proportion of my patients have diabetes what proportion is poorly controlled who hasn't been seen in the past six months and if an organization can do that for the top 10 ambulatory care sensitive conditions those are the organizations that regardless of the payment model they're going to succeed because they're able to find the patients who are most likely to become costly and better manage that and and the service that you folks are providing is the service that can help the clinicians do it but really having that end user idea in mind ambulatory care sensitive conditions that are poorly controlled how do we get that information to clinicians um that's just that's it's really hard I don't know any place that does it consistently great but um just I'm just trying to advocate for um really focusing in on that with everything that you do yeah yeah I just keep doing the great job you're doing um but really try to be able to tell me what proportion of my patients have diabetes that is and thank you for bringing that up that is definitely we hear that and and we understand that and some of the work that we're we've got planned this message archive and some of the apis are hopefully building blocks to be able to do some of that and make that data available at the point of care so I'm not promising that's happening in the next four months but it is building towards that right we're taking our first steps to this year have um a dashboard which is more about data completeness as a first step for organizations so before we can start telling you or before we want to start representing to you like we're sure we have the data and this about your patient hey here's what you submitted to us does this really jive with what you think you're submitted is the more data you should be submitting so we can have a more complete picture and then building from there um be sharing with organizations more dashboards into the data so it's absolutely something we have we're we're we're going to start taking some steps on this year great and and the work you just mentioned you can't skip right it's so so it's in those are important steps and so good job and and keep going um does the healthcare advocate have any questions or comments on this thank you we just just just a few um you know the work on apis is really interesting I think at least in other fields and obviously it's different in healthcare um and with fire data but you know there are some really interesting use cases that I think you couldn't have predicted that people would use the data or use api in the way that it's intended and I think at least personally I've sometimes heard about those and that has changed how I'm approaching the project so I'm thinking like really early examples of how folks were using calls to the um ny city data repository right like yeah that was really interesting to hear like there was all these ways that people were using this urban planning data that wasn't expected right like we couldn't have thought that people would use these standardized calls in that way or for instance most recently like thinking about how web developers are using the api that was developed that was put out by heroku right like you couldn't have expected some of these uses right and then you're looking around and trying to put something together and like oh my god that's a great idea I should use the api in this way and obviously it's different in the healthcare space um but I think that would be an interesting thing to track and a kind of within bounds moving the beyond just interoperability of the EHRs but really getting that innovation around looking at the social determinants of health and how we're incorporating that equity thinking um it would be really interesting to say um and uh chair foster I just wanted to say weird but so without the um kind of ethical problems perhaps the and in the kind of criminal law enforcement context weirdly it's sometimes useful to think of to look at Palantir and vital so really without the ethical issues I want to be clear here like we can have our own judgments on Palantir and what they do but I think it's that the role and the insights that data standardization and interoperability can do um Palantir is an interesting use case for that all other issues aside and then lastly I know I just want to say this because there are so many new board members um vital efforts at community outreach and really translating rather complex ideas in an understandable way is they take very seriously in my opinion and you know it's I think it's a interesting to look at as several board members have raised about how as an example for how you can communicate quite complex ideas in a accessible format thank you so much thank you um you know I echo what uh Mr. Shultai said about your ability to translate this for uh layfolk so I appreciate that um and I believe you have some additional material to cover which we'll go through before we do public comment thank you I'm sorry you'll be done with me soon this yeah while you're pulling that up uh I'll jump in um hi everyone I'm Kate O'Neill I'm the director of data analytics here at the Green Mountain Care Board so uh I am chiming in because this is related to a proposed amendment to the HIE plan Beth and her and the vital team will talk through uh a change that they propose but it is a mid-year change to the state's HIE plan which you approved back in December and it's related to appendix A so I just uh wanted to come on first to let you know that this is part of the process right so if there's a mid-year change to the HIE plan per statute the board um will contemplate the change and uh and and vote on approval for it so I'm here to let you know that the HIE Steering Committee has reviewed this change and did vote to to approve it so now it moves to the Green Mountain Care Board um I think Beth that I'll stop here there's no vote on this today this is just for you to uh to learn about and uh and to understand ask questions about uh and then uh at the end of May along with the vote for the budget uh you'll vote on this proposed amendment so Beth I'll turn it over to you to explain the change and the rationale for it thanks can you see my slides yeah great perfect thank you um one thanks team doesn't tell you as it's actually showing um so thank you Kate for the introduction just gonna stress again I'm I'm asking for this request which was approved by the HIE Steering Committee last month so I'm it's gone through process the committee had a long discussion about this change and approved it to come forward um and so just a quick context setting you can you approve the HIE strategic plan on an annual basis appendix A of that plan and while the plan sets out goals for what we want to do functionality capabilities what direction we want to go appendix A really lays out protocols for access to protected health information on the v high right that's the name of it and it really does um set standards for who can have access now that appendix A is you is um guidance is also used in conjunction with the services agreements we have in place with the healthcare organizations that follow kind of traditional um business associate um to the HIPAA TPO use or I'm sorry and we'll use acronyms treatment payment operations um access to the healthcare data and also subject to the patient consent right first and foremost that that's what drives our sharing of the data um but but this really is protocols that change on annual basis as we learn new new capabilities or types of data that we might want to have in the HIE and this morphs and so one change that was included um with in November was to enable us to participate in some uh to represent that we do participate in some national exchange so there's a organization's e-health exchange we participate in a lot of HIEs and healthcare organizations participate in and they facilitate sharing of healthcare data across organizations so it's another way that we can make patient data accessible we traditionally have worked with the e-health exchange to make the the v-hide data available to and you heard Maureen talk about this a bit before to UVM and so they've been able to within their epic instance actually access v-hide data about their patients so again they don't want to log into our portal they can pull up some some patient information in and within their EHR and also to the the Veterans Association and the Department of Defense for their medical operations so it's not for their general operations but it's for the healthcare that they provide to veterans or active military and it's within their it's called a joint HIE or jai and we've had that link directly before but the new model for e-health exchange treats it differently on a hub model and we wanted to protect and continue that work with UVM via in DOD and so included in the change to the appendix a in November that capability but the world has changed a lot and and e-health exchange their model has changed significantly and we the real goal for them is interoperability and opening access for healthcare data more broadly right national exchange and this aligns with ONC and HHS guidance at the federal level we also know that changes to some laws in many states around reproductive and gender affirming care has maybe put risk with sharing some data and in different states it's changed the risk it's changed the calculation and so we don't want at this point we want to continue that work with UVM via in DOD but we don't want to open up access to the HIE data to other organizations until we can have some really thoughtful conversations with the HIE steering committee and participants and patients across the state to understand what people are comfortable with we also want to see what's happening on a national level right HHS has issued a notice of public rulemaking for changes to the hyper privacy rule around reproductive data and we want to see what that what that means to us and what that how that changes how how that data needs to be shared or accessed and so we'd like to make this change to appendix a which will limit how we can share the data with e-health exchange so it will protect us as an organization from any claims of information blocking or pressures we might get to share our data on a more national basis until we exist making it comfortable with our approach and what what is right and appropriate for sharing reproductive and gender affirming care data and we'll do some of that work with the HIE steering committee over the coming months but so this will allow us to not be or protect us from being claims of information blocking or push to get to make the data more broadly available but would allow us to continue our work with the UVM VA and DOD to make that data available so it's a simple addition of some language within appendix a and it's in section seven B where we want to say we're vital in coordination with and subject to the approval of the HIE steering committee so we have some firm language to say the HIE steering committee has or hasn't approved something for us to not to not be put in an awkward position of information blocking but also allow for some really thoughtful conversations and guidance around the data governance around the types of data that we may have concerns about or how it might be used differently in other states so the proposal is really just the insertion of that and subject to the approval of which is in red on the slide that is my request I'm happy to answer any questions on that one great um I don't have any questions we haven't noticed a vote um but I'll open up the other board members for any questions or comments they have on this I have a couple questions um one really isn't so much for you Beth but I think by statute diva has to propose changes to the HIE plan so I think at minimum we need to get something from diva in order for it to be compliant with the statute but I'll leave that to our legal team to consider um so that's that's just a technical thing I wanted to kind of put out there um the other is if I remember correctly that there are now or there were going to be implemented information blocking penalties and could you just you mentioned the concern about not you know information blocking but could you remind us a little bit more detail about why that is important yes so as part of the 21st century CARES Act and and really this kind of push from HHS and ONC to encourage the accessibility of patient data for patient access to the data they put in place what are referred to as information blocking rules but they're really rules against information blocking and making sure that patient data is made accessible and we and um patients or or providers can make claims against organizations that have health data that do not share patient data now it's supposed to be patient directed access to the data there's some intricacies or you know kind of nuances to what the rules are but when we participate in a national exchange like a health exchange the expectation is is we would open up for kind of more broad sharing of the data and we want this protection to protect that as far as I've heard and this may not be completely accurate still there have certainly been claims of information blocking made to ONC um not against us I'm sorry to be clear but against some other health care organizations but I haven't heard of actual penalties imposed as of yet and there was a lot of um uh lack of specificity and some of what those penalties might look like in the actual rules and haven't really seen a lot of um um penalties come certainly claims certainly claims substantiated but I don't know that specific penalties have been implemented yet thank you that's just good to have a little more context around the request thank you I guess I have one other follow-up question which is um are you thinking that you might explore an alternative to continuing the connections with UVM and the VA and DOD other than the e-health exchange? um the VA and DOD this is really the way that they want to operate um so I don't think there's another option for making that data available and we do get you've seen the numbers we do they do use the data and so we don't want to shut that down we have we have a lot you know we do have a presence in in Vermont and we obviously people go to other states and want access to that data um UVM there might be other ways but this is built in and kind of I'm gonna say easy and the IT people would laugh at me but this is a great consistent way that this can get into their EHR and they get this data not just from us but others in the same kind of location so would want it for that consistency and I think there are other um other healthcare organizations who might also have that same functionality that they would want it I you know we would you know other hospitals in Vermont may also want this access and we would want to be able to enable it there thank you any other board member questions or comments okay uh healthcare advocate do you have anything on this just that we fully support the amendment great thank you um and I'll open up to public comment on any of the vital information that was presented today uh Mr. Ham Davis how are you please go ahead thank you Mr. Chairman I'm curious this is I don't know if it can be a question or a comment but I'm curious whether since I think it's clear that the main issue in uh in communication between various medical units is essentially vertical it's in other words a primary care hospital in Newport is if they get to have a problem then they're not they're not they're not going to call they're not going to call Springfield what they're going to do is they're going to call Dartmouth they're going to go up and down the severity uh plane and so what I'm curious about is uh does the does is an epic system which is the most expensive and elaborate and powerful system IT system in the state and I think is used both by UVM which is half all of the care and then by Dartmouth which is a huge piece of tertiary care on the Connecticut River and all the way into the all the way into central Vermont does the does the um does this within the epic arena within the boundaries of epic um there's the problem that you've had uh get does that does this uh difficulty exist this difficulty of constantly matching information bits of information flow um vital team if you would like to answer the question you can um otherwise we can treat it as public comment up to you if you have an answer that's fine if not that's okay I can give a general answer just because I want to respond and I want to make sure I understand so you're can I paraphrase just to ask if I'm understanding it correctly yeah please go ahead is the question really because they use the same system should they be able to to share data directly like should there be yes that that's that that is precisely at that understanding anyway which could be wrong that is that the entire purpose of that the whole purpose of epic in the first place is to um is to enable an unimpeded flow of medical information up and down the system somebody goes to a primary care doctor and they go to a hospital they go maybe go then they maybe go to tertiary center then it may have to go somewhere so the question my question is whether um that that to the extent to which you the general problem that you're dealing with I'm curious to the extent to which it is it is obviated whether it's solved whether it's not solved uh within within the within the epic system itself so I don't want to come in fully on epic because we are not an epic customer but I think where we where we do see that that the challenge will continue is we do have a lot of practices and providers in the state that are not on the epic system and we also have the commercial labs and we have the department of health who are all on different systems so even if you know we do you're right we do have two main provider organizations in our state that do use epic but I think we're always surprised and when we have conversations with some of those organizations surprised about the amount of care patients receive outside of those systems in Vermont and so that that will remain to be a challenge for us opportunity for us thank you thank you sir and I I'm sorry oh no you're fine um let me just say one that we have a bit of a timing issue that I didn't appreciate and we're gone a little bit over and so Walter and ham and Sharon if you don't mind I think we should actually hold public come until we're done with everything because one of our staff members has a hard stop um so I'm going to move on I'm going to take a two three minute break here and come back in three minutes and we'll go to the um uh boss request that we received um and I apologize for that um but I just need to make sure our staff member is uh okay on time thank you so we'll be back at two thirty three thank you we're just waiting on uh Tom Walsh so we'll give him a minute right on time perfect timing okay uh we'll resume uh with our meeting and I'll turn it over to our director of health systems finances uh Sarah Lindberg and our staff attorney Russ McCracken to discuss the VAAS request for reconsideration of the fiscal year 24 hospital budget guidance uh thanks for the introduction and thank you Russ for being here uh so we received a letter May 3rd uh the Green Mountain Care Board specifically chair Foster um asking that the fiscal year 24 uh hospital budget guidance uh be reconsidered uh there are essentially two asks uh in the letter uh it's an or as far as I can uh interpret it and that is either uh the benchmark in the 24 guidance uh is increased due to the um financial status of our hospitals or uh that any enforcement for fiscal year 24 would be waived um such as it was for COVID and so just to briefly uh review the letter with you all today um highlighting how critical this ask is um from Mr. Del Treco um and asking for that amendment in our benchmark which as you recall is net patient revenue growth from fiscal year 22 to fiscal year 24 budgets of 8.6 percent in net patient revenue um as we highlighted that would not leave uh really any wiggle room over approved fiscal year 23 budgets and VAAS uh reshared an analysis that they had shared as a public comment during the guidance review about um if you look at um increases over time how detrimental this would be to hospitals bottom lines um so they acknowledge that this guidance does not have the force of law and um I think uh if it hasn't been made clear already that it's clear to me that you know the fiduciary responsibility to your organization would certainly trump um any guidance that we issue um and that the ask would be to help us understand why that um fiduciary responsibility does not uh fit in with the current target um they also talk about risks that they feel to creating great instability to the system um including potentially uh risking having to cut services or um jeopardizing their financial position through violation of debt covenants or downgrading bond ratings um as well as potentially risking uh workforce issues um and so that is highlighted in there um and then uh they think that or the argument in here is that um the amendment would be more in line with our statutory responsibilities so that we can uh support positive operating margins um and so that is uh the long and short of it um I will just say uh you know I think there's been a long ask about trying to develop these targets over multiple years and clearly trying to set something with so many unknowns is a challenge and so I think that one uh important lesson that the board should be thinking about is if we are talking about multi-year targets there probably should be a process in place for either updating or potentially revisiting some of those as more information becomes available potentially but I think that this is kind of tough pension to try to set something for multiple years and then have it um you know asked to be changed midway through when we acknowledge this is something that was set in the past in all fairness there was concerns that it was not adequate when it was set at that time so um there had been some concerns raised back with the fiscal year 23 guidance um so uh I think that the way it'll make the most sense to handle this procedurally is happy to talk about this with the board today but staff are recommending a public comment period for the next week and we can take up the vote at next Wednesday's meeting and that would give the board a chance to gather more information um from Vermonters and other folks impacted by this guidance so that's pretty much all I have to say on this topic I can stop sharing the letter here and address any questions or comments that the board may have. Sure thank you um do any board members have questions or comments? I have just a couple director Lindberg if that's okay um first I would just say that I support public comment on this I think it'll be beneficial so if the recommendations to open it for a week I think that's logical and we should receive that so um I support doing that um and then just a couple quick things vital um earlier spoke about um their cost increases that they've experienced over the last several years which I presume is not you know something that they're experiencing alone if the board were to increase the guidance by the 82 million dollars identified in the letter where would those funds come from if you have a sense? Sure um so net patient revenue increases are agnostic to where the funds specifically come for but historically the area where we kind of try to fill the gap tends to be in the commercial rate ask so it's the prices that commercial rate payers pay at hospitals if there is a delta between what um the government is able to pay and what is needed to fund operations. Okay so it could be from Medicaid, Medicare historically it's generally commercial. Correct and the only other question I had um I think my understanding is correct but in previous years hospitals have come in above guidance is that right? Yes and previously the board has approved um requests above guidance is that correct? Yes and if a hospital this year feels appropriate and necessary to submit a request above guidance could you explain the process to us of how we would review that? Sure um we'll be using a process similar to the one we used last year where for those that are above guidance we understand we look into the evidence that the filing has to support that in that request that's above the guidance and so this year we further focus that to try to organize that in looking at expense growth specifically and where expenses are and assuming you know that's all um built on reasonable assumptions which by and large is what we saw last year we looked to see if there's any developing information about changes to governmental rates potentially that might impact that request and that that's how we handled that last year so it's you know just trying to understand the evidence supporting the request. One of the things highlighted in this letter as a concern um is the short turnaround between um when the board makes a decision and when they have to begin operating under that budget. Is there anything that we can do about that or to address that concern because I do think it seems like a valid concern? Yes um so that is I think a bigger question that the board has wrestled with for a long time but how what ways if if any can we kind of adjust our regulatory calendar to reduce some of that tension and you know there's I think you know again if we're going to some sort of multi-year process that might offer us more opportunity to expedite that but we are also working around the rate review calendar which is challenging for the board. That's set by statute. So the the QHP rate review process is federal law, hospitals, fiscal years are set by state statute and the deadlines for our hospital budget process are we must have the decisions by September 15th is in statute but many of the other deadlines are either in rule or guidance. I don't have any other questions thank you for that. And Russ correct me if I got any of that wrong please. Any other board members? But I just uh pick you back one quick question on what you asked if Sarah do you have any idea roughly speaking if there was an 86 million dollar increase to commercial insurance what that would be roughly in a commercial insurance rate increase for that group of people? So it depends we have to remember that you know the hospital prices increases for Vermont hospitals is just a portion of the premium that any commercial plan would feel and there's going to be a great deal of variability depending on the plan and the cost sharing of that plan in terms of the net impact to a consumer. So it's a difficult thing to spitball on and varies greatly depending on the consumer situation. Happy to try to model some of that at a high level but it's going to be imperfect to a high degree. Do you know since we know last year's commercial rate increase do you know what the total amount of NPR generated the total increase in NPR generated from commercial insurance would have been in last year's rate to sort of estimate what that would mean to this year's rate? Um yeah I think that um I lost track of what kind of rate we're talking about I'm sorry are we talking about premium? Well we talk about commercial insurance rate increases yeah I guess if I would say premium rate increases. Okay so what I can fairly easily do is look at how much revenue has changed and a high level utilization has changed by a payer type but again that's you know marginal and a little tricky but I can certainly pull that together to review for next week. That'd be helpful thanks. Yeah no problem. Health care advocate do you have any questions or comments? Good afternoon um Sam Prash off to the health care advocate and I'll make a few brief comments and then I'll turn over to Mike for sure. We recommend that the board actually stand by the approved guidance it's already been approved by the board after a pretty extended and open process that both VOS and the HCA participated in and just echo a couple points that you said chair Foster nothing prevents hospitals from proposing a budget that exceeds the guidance I think page six lays this out pretty clearly. If a hospital's budget exceeds the NPR FPP growth the board will review the specifics and support for the growth provided the hospital and its criteria using the factors and criteria and the guidance and as you pointed out it's not uncommon that historically hospitals submit budgets that exceed that guidance and these have always been considered and oftentimes they've been submitted as approved or approved as submitted rather and or approved with minor modifications and I think given that we're a month and a half out from when we expect to receive budgets I think there's a logistical concern too to prolonging this process that I think we've all participated in in an open and collaborative way so I'll leave it that in turn to Mike thanks. Good afternoon board I just want to do a double check that you can hear me. So two very simple points I want to make one of them is that well you know Vermonters clearly need sustainable hospitals. Vermonters also need sustainable independent providers and we have a fear that an unintended consequence of the board regulating hospitals and not hospital budgets and not regulating independent provider budgets is that hospitals end up getting an assured revenue stream through the hospital budget process and to the detriment of independent providers so I wanted to make that point. I also wanted to make the traditional comment you would expect from me about affordability and I think the you know the discussion earlier about small group is small group rates is appropriate given for this year for next year and the year after the enhanced premium tax credits individuals are significantly protected from from rate increases but small businesses aren't. Small businesses including municipalities including nonprofit sector and and you know I would report very similarly about Vermont legal aides the pressures on Vermont legal aid also in the exchange. So you know I want to with as much passion as I can give recognize the challenges that Vermonters are facing today if you haven't noticed everything is more expensive everything and and Vermonters are feeling that and and calling our office with you know real concerns when they have health care expenses and I just want to make sure that that concern I know that concern is on your minds but I thought it important to say it out loud here that as you consider changes to the hospital budget guidance that the other side of the equation is who's going to pay for it. Thank you. Thank you. I think I think you sort of summarized our challenges pretty well. We need sustainable hospitals, independence and affordability it's really obviously something we grapple with every day. I'm going to open up to public comment on this so that folks don't have to wait till after the ACO presentation. I see a couple hands up. Ms. Gutwin, how are you please go ahead. Thanks. I'll be brief this time because Mike actually has already said what's most important to my heart. So thanks Mike. I just also wanted to say I appreciate the conversation after the presentation, especially what Tom said that the best value of a common health information database a common health information database is what will be helpful to providers in managing chronic disease. Six out of 10 adults have some form of chronic disease and so while immunizations are important it's it's my news compared to the big apple and so any efforts really if we're going to get a bang for the buck it's got to be the sharing of what goes into chronic care management and Tom articulated that very well. Thanks. Thank you very much for your comment. Mr. Davis, I think you're next please go ahead. Thank you. I think we're just now talking about Mike Del Trecos in his issue here while we're going back to the previous. Let's keep it exciting. Let's do either. Okay. Insofar as the guidance is concerned, number one I just think it makes no sense to do two-year guidance. I never don't think it ever made any sense and it becomes irrelevant by the second year. It just doesn't work at all. Secondly, I think that given the way that health care is the whole issue of supplier induced demand and that kind of thing that the that the issue ought to be not a net patient revenue per se but or but what it really should be should be cost per capita in the service area which would conform to some of the kind of data you get in the Dartmouth. The Dartmouth Health Atlas. That's my opinion. Thank you. Thank you for those thoughts. Mr. Del Treco. Mr. Treco, just I'll identify you as the author of the request. It's just so folks know but please go ahead. Yeah, thank you. I appreciate that. I also want to thank the board for taking this issue up today. I know how important this work is and additionally I want the board to know that not only not only myself but the entire board takes this request very seriously and ahead of sending this letter we worked for over a month to try to evaluate how to manage the guidance in its current form. The guidance creates basically two options. One to be in compliance or two to be out of compliance. So if we remain in compliance with the guidance I think we will certainly exacerbate the current issues related to our ability to meet patient demand along with our ability to invest in our communities and our staff. This is not a simple issue. This will further erode access, challenge our ability to meet debt obligations, increase the chance that bond ratings and downgrades may happen and likely jeopardize the solvency of some of our organizations. If we're out of compliance we enter into a space as you mentioned of great uncertainty. We'll need to wait for the hearing process to unfold and for our budget orders to be finalized to understand the resources we have to run our operations. Both of these situations are not pretty and they are sure to deteriorate public perception on the work we do. We need guidance that we need guidance that reflects the economic realities of what we are faced with today. In 2023, guidance did just that. The growth rate was set and an approved 8.6% and those budgets were approved at 8.5%. The economic pressures that we recognized in 2023 remained. Inflation is still very high. The workforce challenges remain and the predictability of supply chain changes daily. In this moment, it's difficult to understand how the board and your deliberation of setting the guidance allowed for a 0.1% growth rate from 2023. I appreciate the time to digest and think about public comment. We'll work on that and be back in touch with you. I do want to speak to a comment that's been made around what has historically happened if a hospital has gone over guidance. Just let me frame this out for a moment. A lot of work historically has gone up on the front end of development of guidance where that guidance around net patient service revenue growth was more tied to some of the economic pressures. When hospitals submitted their budgets in July of the year that we would be dealing with, the magnitude of change from the guidance has been relatively small. In this instance, we would see quite the contrary. We would see hospitals submitting budgets far exceeding the guidance as it's been outlined. That in itself creates an incredible problem. It's not apples to apples what has happened historically to what is happening today. Again, I think having a 0.1% growth rate from current 23 is a very difficult concept to understand and how that rate was set. Thank you for the time, and I really appreciate the opportunity to speak. Thank you for those points and for your request. Mr. Tester, could you identify where you're from if you're associated with a regulated entity? Please go ahead. Sure, absolutely. Thank you for taking my comments. I'm Sean Tester. I'm the CEO of Northeastern Vermont Regional Hospital and a member of VAAS. I really also appreciate you guys taking this up. I think many of the long-time board members here will recognize that NVRH, we've always tried very hard to take into consideration the guidance that's given us and tried to provide a budget that was reasonable. Although sometimes over that guidance, it was always reasonable and justifiable. I think the chance we're facing is this is the first time where as we put together our budget and you look at the pressures we're facing that we're going to be significantly over that guidance and without jeopardizing the care in our community. Mike Fisher really summed it up well when you said everything is more expensive right now, and that couldn't be more true for health care inflation. The market rate inflation we're seeing on our critical workforce is just beyond anything that we ever imagined could happen over the course of a couple of years and we don't see that abating. I know all of you have seen the results year to date for the Vermont's hospitals. It doesn't look pretty and I can share with you that we just closed the books on April and April we had a $460,000 loss along. This is not getting better folks. We have currently here at the hospital I have over 60 job openings that were unable to fill and I have 22 travelers on staff. And while traveler rates have come down somewhat, that is still creating a gaping wound hole in our financials. And it's coming down to difficult choices. Do we staff up with travelers or do I limit beds on our med and surge floor? Because those are difficult decisions that we're being forced into. This will have a direct impact on our ability to meet the community's health care needs. So I just encourage all of you to be thoughtful as you go through this process. Thank you. Thank you very much for those thoughts Mr. Tester. And Walter I apologize I skipped over you. I think you were next so I apologize but please go ahead. Well no worries Owen. Sorry and how I'm dressed. I'm here at the the state park where I work and it's about 35 below zero right now with snowing earlier here. I was really just asking about vital but I want to just to back up what Mike Fisher said and to say that and also as well and also Owen when he was asking about who pays for this is who pays for this it's us it comes out of our pockets all the hospital budgets everything as we all know it. Our wages don't rise to meet these increased costs so I guess I'll just end it there. I mean Mike said Vermonters are struggling yes we are my cost just went up by 300 bucks a month now and it's just at some point you can't go any higher or we're all going to be broke. So in a way I agree with the budget guidance through that amendment. Walter did you have anything on vital you want to share as well or I just wanted to ask the vital people about can about patients being able to look at their records or whatever. I had a situation way back in the 1980s before the digital age or when it was just being born where my father was seriously ill and he had a medical evaluation that basically said that you know he's not coming back and we're not going to bother to help him and we couldn't find out who gave that evaluation and I was just wondering if the same situation had happened in the digital vital age could I as a patient or a family member of a patient been able to go back through the records. So I can answer that question for you. We welcome Vermonters to request their records through the Vermont Health Information Exchange. We regularly deliver Vermonters who have made this request their their record everything that all of the information that is available about their care that's available in the Vermont Health Information Exchange we can send that to you. Certainly there's we're very careful about who we make that available to and there needs to be sort of like a notarized form saying that you are the person requesting your information. Now if you are an authorized representative of another person and legally have the right to their record that is also possible. So record request. And how would the average how would the average Joe or Mary Vermonter figure that out? So there's information about that on our website and we certainly welcome folks to to call and talk to our support team and they can help help you with that request or help any Vermonter with that request. Does that answer the question? Getting there but I'll let others go. Okay. Thank you. And Mr. Peter Wright if you could identify yourself and please go ahead. Thank you Chair Foster. My name is Peter Wright. I'm the Chief Executive Officer of Northwestern Medical Center here in St. Albans Vermont. I just want to echo some of the comments and put some real life connection to some of the consequences. As we put together our budget and look at this guidance as it stands today we would be forced to make a decision about following the guidance to the letter, meeting our fiduciary responsibilities and ensuring that we can meet our excuse me debt covenants and other obligations as well as the most important part which is being able to serve the community. So being hamstrung into kind of saying there's going to be a rate cap or an expense cap we would have to do somewhat draconian measures like cap inpatient census and say okay I'm no longer going to hire more traveling nurses as Mr. Tester said and thus instead of a census of 38 being my capable capacity I may have to bring it down to 32 or 28 you know not enabling us to serve the community the way we've been put here to do and then putting more downward pressure on inpatient capacity and other hospitals particularly the medical center which is as you know tight on a very good day. I did also want to make one more comment and I was stringing some connections together there seemed to be a conversation earlier about you know if hospital rate increases were improved what would that mean for insurance premium rate increases for commercial payers and I think there's a long history in the state of Vermont of a disconnection between hospital rates and insurance premiums there's plenty of examples where rates have not gone up in a particular market yet for a hospital yet gone up for businesses and insurance carriers so I think it's important just to kind of say there is not a direct link between if you raise x percent in a hospital budget that will increase the premium of a commercial insurance carrier in that market thank you for the time great and thank you for attending and participating today. Any other public comment on this okay great director Lindenberg and Mr. McCracken thank you very much and have a good day I think Russ we might see you again in a minute but Sarah have a good day. We'll turn next to the one care Vermont revised budget we have a staff presentation. Before we do that Chair Foster if you don't mind I just want to confirm we're going to open a special public comment period on this request have it open for a week come back at the next board meeting next Wednesday for an opportunity for the board to vote on the request at that point. That's fine with me if you think that's sufficient time for all their scheduling needs based on all the deadlines we have on that that's perfectly reasonable. Yep we'll do that okay thanks for clarifying Russ all right thanks all thank you and so we will be hearing about one care from Michelle Sawyer our health policy project director and Marissa Malamed our associate director of health systems policy and Mr. McCracken of course so Ms. Sawyer I'll turn it to you. Thank you very much Chair Foster good afternoon as Chair Foster said I am Michelle Sawyer health policy project director with the Green Mountain Care Board. I am joined today by Marissa Malamed associate director of health systems policy and Russ McCracken staff attorney. We are here today to further discuss one care Vermont's fiscal year 23 certification status the benchmarking report and the revised budget. So the agenda for this afternoon we will start with an update on one care certification eligibility verification then Marissa will provide an update on the benchmarking report and I will present some slides regarding the revised budget analysis starting with a couple of background slides a review of one care's changes in their risk model and population health programs and then we'll wrap up with Russ walking us through a staff recommendation for the board to consider. And I did just want to make a note about the scope of the revised budget review in particular. The staff in the board are here today to consider changes that have been made since the last time that the board approved one care's budget with conditions. So the items that were unchanged between the initial and the revised budget are not topics for conversation or discussion today as they were previously analyzed and ultimately approved by the board back in December. This slide also shows a timeline and I'll just highlight those last couple of dates that there is a potential vote scheduled for next Wednesday and then if we need it there is an additional potential vote scheduled. So we'll start with the certification update. So the Green Mountain Care Board staff have completed their review of one care's fiscal year 23 certification eligibility verification and we will be sending a memo to the board later this week covering a review of each section of the rule. The memo will be posted publicly on the Green Mountain Care Board website when it is completed. And the staff have concluded that the eligibility requirements for fiscal year 23 are being met. However given the level of interest among board members around executive compensation under rule 5 section 5.203A the staff have requested additional information from one care which may inform the staff's recommendation for fiscal year 24 certification and budget guidance. And those guidances will be presented to the board in June and voted on before July 1st. I will now hand it over to Marissa to discuss the benchmarking reports. Thank you Michelle and good afternoon to the board members of the public. I'm going to review where we're at on the status of the benchmarking report requirement. So on May 3rd we discussed the one care Vermont Medicare performance benchmarking report submission against the budget order requirements that's condition one. On May 5th one care presented their revised budget including a presentation of their benchmarking report and results. And in addition the Green Mountain Care Board staff met with one care and their benchmarking vendor with the HCA as well last week to review report usability considerations and methodological concerns. Today I will present the staff recommendation in next step for this requirement. You can go to the next slide. So as a reminder the ultimate objective for the Green Mountain Care Board is to have a valid report to use to track relevant performance metrics over time and to understand how one care Vermont uses those metrics to set clinical priorities and make budgeting decisions. At our last staff presentation I shared the following questions as discussion guides for reviewing this requirement. So I just want to make to Michelle's point at the beginning. I just want to make clear that there is a budget condition number one. This is more of a review of the status. The staff isn't recommending any changes to that condition. So we're bringing this up today as sort of this is where we're at because this has been you know a bit of a process to to work through. So I'm bringing these questions back up because they were presented or shown on on May 3rd and I want to just talk through where we're at with them a little bit. So the first question is the development of this report has been an iterative process between Green Mountain Care Board one care and their vendor is the Green Mountain Care Board ready to accept this report for use as a consistent performance measurement tool. Does one care intend to use this report in creating their budget and their quality evaluation improvement program. So as we've sort of worked through this process in the discussion what we've been hearing as a staff is that we are ready to move forward with this report and and use it the way is intended with some changes that I'm going to review that have been discussed and that you know one care has talked about how they intend to use the report for their for their budget and quality evaluation improvement program and that's something that we will look for as we move forward with guidance and and the 24 budget submission question to and then we can open up discussion on this as the board discusses this so I'm just going to go through kind of what we what we've heard on this so far number two is the Green Mountain Care Board required establishing ACO performance benchmarks to help answer the following questions how well can an ACO perform in each metric metric how does one care Vermont perform in each metric in comparison to an ACO that gets the best results in each metric. So last in the past couple of meetings we talked through the two different cohorts sort of their strengths and weaknesses and we believe that you know with some limitations as any report has the report can be used to understand sort of best practices or sorry sorry not best practices best performance and comparison to like ACOs best practices a little different we can talk about that. Next slide question three we asked and discussed with the vendor specifically does the March 31st report allow GFCB to track one care performance over time so is it is it valid to show those measures and look at them year over year and they confirm that it is we have a sort of proposal that we're looking at to show that more clearly. Question four question four and five are a little bit are a little bit ongoing but we have had good discussions about them one of the strengths and weaknesses of this report to show us the relationship between one care's efforts and performance improvement as I think this board and anyone else who's been following this work is very aware it's extremely difficult to make a causal link between specific programs and performance so there's going to be a number of things that we would need to look at to to sort of understand the relationship between one care efforts and performance improvement so I think and you know we believe that this report can be used as as one you know piece of information to look at and we hope to better kind of outline that the strengths and weaknesses there as we as we go forward using the report and then number five is this report allow one care to calculate the return on investment of population health investments payment initiatives and administrative expenses I believe the answer to that is that it it does not directly but we have heard from one care and discussed in in previous presentations how that this might be done going forward so again making it part of sort of the different evaluative tools that the board can use to look at how one care performance so with that slide nine here is a summary of the things that we've discussed over the past couple of weeks to make some improvements to the to the next iteration of the report and that is that each report submission would be accompanied by the following thing a description of the comparison cohorts and exclusion criteria so making sure that that kind of follows each report so that it's clear to anyone reading and interpreting the report a description of the benchmarking methodology that is how the metrics and the benchmarks are calculated the data sources and data dictionary any limitations caveats or interpretation notes an executive summary of the results and then a year over year trend report excuse me for selected metrics so the following slide 10 is is next steps for this requirement and that will be make sure that this is communicated clearly with one care we've you know we've had conversations with them and we'll we want to make sure that the expectations are clear and this is one step in that process including any additional you know comments questions or concerns that board members want to discuss here we intend to develop the year over year trend report for selected metrics to include in the FY 24 guidance development so I showed a template of that report at the May 3rd presentation one care also had a version of a bar chart version of year over year metrics and we would like to have a sort of come together on what that is going to look like for the next the next report which also the requirements for that would be would be included in the guidance which we are working on basically as we speak this season and then third the FY 24 certified ACO guidance is expected to include requirements to type performance benchmarks to the budget so that is an understanding of that objective that I stated in the beginning you know understanding how one care is making budgeting decisions based on performance outcome and that is all I have on an update on the benchmarking report pass it back to Michelle for the revised budget analysis. Thank you Marissa. All right so the budget guidance issued to one care as well as the budget order require a revised budget to be presented in the spring of the budget year. One care presented their budget last Friday May 5th which included elements described in the fiscal year 23 budget order as well as other changes made between the initial and revised budgets. I want to highlight that the board may adjust an ACO's budget if they find its performance has varied substantially from its approved budget which in the case of one care is the budget approved last December and this slide is really here for reference this is the section of rule 5 that gives the Green Mountain Care Board the authority to adjust an ACO's budget. This list highlights areas where one care's performance has varied substantially from the last approved budget all of the items on this list were presented by one care during their hearing. You may notice this list does not include any of the Green Mountain Care Board ordered changes such as the 2% administrative expense cut or the increase in one care held risk for the Medicare advanced state shared savings dollars. The list also omits the two million dollars from diva being paid directly to providers from for PHM bonus earnings as this change was not material to how the programs operate or the finance financials of the PHM program given that one care attentively accounted for those diva dollars in their initial budget. So there has been a significant reduction in the amount of risk held by the entire network and the providers. In the revised budget the amount of upside potential earnings is reduced by about 9.8 million at the network level and it's reduced by 9.9 million at the provider level. The downside risk is reduced by 1.4 million for the network and 5 million for the providers. In addition to the board ordered Medicare advanced shared savings dollars that one care now carries its risk these changes came about because of the loss of the Blue Cross Blue Shield Vermont payer program the addition of the new UVM health network self-funded payer program and due to changes in the risk corridors for both the Medicaid and the MVP programs between the initial and revised budgets. We heard from one care during their hearing on the 5th about changes made to their population health programs. The PHM program itself had a reduction in funding due mainly to the loss of the Blue Cross attributed lives while the diva funding model changed between the budgets. As I mentioned divas amount of $2 million into the PHM program through direct provider payments did not change. On this slide under the total row you can see a reduction of about 3.7 million but the diva payments to providers for PHM bonus earnings reduces that shortfall by 2 million so the difference between the two budgets is essentially 1.6 million for population health efforts. One notable program change is the addition of the mental health screening and follow-up initiative and there was also a change to the CPR program that arranged for MVP lives to be included in the count of attributed lives for those providers participating in the CPR program. I'm going to hand it over to Russ now to walk us through the staff recommendation. Thank you Michelle. So this is a different situation than the board has been in historically in past years. The final budget that One Care submitted in March really didn't have anything materially different than the budget that the board had approved back in the fall. So we haven't encountered this particular situation where the current approved One Care budget is the budget One Care submitted to the board back in the fall and the board approved. It has some substantial differences which Michelle walked through that were clear from the material submitted by One Care and One Care's presentation to the board. The fact that there is this difference has been communicated to One Care but it hasn't been communicated by the full board in the form of a finding. We have some concerns and we see an issue with One Care operating under a budget that has some pretty significant differences from what the board had approved. So it's really up to One Care to request an amendment. The board can't make the change or update the board's approval without application from One Care and that's set out in rule 5.407 which Michelle showed earlier. So what we're proposing here is the next step is again following the performance review provisions of rule 5.407. The board make a determination that the ACO's performance has varied substantially from its budget and the board provide written notice of that to the ACO which will be in the form of a letter. That's our recommendation. I'm happy to take questions. I think this is a deficiency that is pretty easy, could be pretty easy to cure from One Care with a request that the board updated its budget approval to reflect what is the final budget that it's operating under. But at this stage, given where we are, we recommend the board make this determination and send it in writing to One Care. Great. Thank you both. I'll open it up to the board members for any questions or comments. I have a couple. First, I wanted to observe that I think that this benchmarking in the report that we got, it's really great and gives us in the sense that it gives us an opportunity in One Care and opportunity to identify where they can make a difference and how they can focus some of their programmatic efforts and their investments, which historically I don't think has been available. We just heard from the hospitals, a couple hospital executives and VAZ about the very concerning financial challenges they have. And we heard about independent practices, financial challenges, and we've heard about people's ability to afford and pay for care. And so we're sort of at a time where it couldn't be more timely for One Care to have these data points as to where they can focus their investments to try and tackle through their work some of our biggest challenges. So we can identify them, they can be measured, and we can see if they're working. And so I think it's a really hopeful and optimistic that we see that happen and then we see some of those measures where One Care was underperforming, see the gap close to the cohorts that they're compared to, and where they do well, even improve on that if possible. And I think next year when we have the information, we'll be able to look at the budget more granularly with that information. So I'm really excited about the opportunity that's here for One Care and the benchmarking that we have and just tying through need and work efforts. So I think that's a great step. I had a couple of quick questions. It sounds like we'll be using the benchmarking primarily right now in our guidance work. Is that correct, Michelle? Yes. I will hand it to Marissa for benchmarking related questions, but that is the intention. And I can speak to that a little bit more. As Marissa described, I think what we'll really use this report for is being able to tie specific metrics that we're seeing, One Care, maybe there's room for improvement, and then being able to identify where in their budget they are prioritizing improvement in those areas. So we're really looking forward to be able to use this as a tool for regulatory purposes as well. Great. And then I had flagged an issue last time we were here relating to the potential concern relating to the PHM, PCP payments to hospitals and ensuring that it actually is going to primary care efforts. Can you update me on where we are on that? Are we doing it in guidance? Are we doing it in hospital budgets or any sort of suggestions around that? Sure. That is an area that the staff are, as we're drafting guidance for next year, I think it probably will appear there. Some ways to get at that. I do also think that there's room for, you know, exploring that on the hospital budget side as well. But I do think that in our ACO oversight tasks that we might be able to make some progress in that realm. And on the suggested motion language, I don't think it's necessary for a regulator to provide advanced notice, although it sounds like here we did. Russ, could you just describe for us any notice that was provided to One Care relating to this compliance issue? Sure, Chair Foster. First, I would point to a letter that you sent to One Care in February, I believe, specifically calling One Care out of compliance with their budget order. I think that letter was received with an invitation to the full board to take action under the rule as needed. But I don't want to summarize all that. I also had a brief call with One Care's in-house counsel where I expressed my opinion that I thought One Care would want to be operating under an approved budget and also that it really needs the request for a budget amendment rather needs to come from One Care and isn't going to be imposed by the Green Mountain Care Board. Thank you. I have no other questions or comments other than to say that I would support the motion given that history. Thank you. I do have one question. Russ, in your conversation it was do we know why they haven't submitted a budget amendment request? I do not. And if we don't, that's fine. I just thought I'd ask. No, thank you for the question. I don't know, so I won't answer. Russ, I have one quick question, too. Maybe this was covered and I need a refresher, but what are the legal or meaningful implications of One Care running their organization under approved budget that is substantially different, where their current budget is substantially different from their approved budget? Well, the board approves a budget and I think the reason that we do that is with understanding that an entity is going to operate generally within the parameters of that budget, you know, that there are some variations. Operating sort of far outside of that, I think opens up other potential areas under the rule of enforcement action. For example, 547D says the board may take any and all actions within its power to compel compliance with an established budget. So I think a regulated entity wants its established budget to reflect its actual performance as one example. I don't have any further questions. Any other questions or comments from the board? I will turn it to the health care advocate. Thank you. Sorry, a little slow, get enough of you. Member Lunge asked the question that I was going to ask. We support the staff recommendation. And I'll just add that I think I just want to thank the board staff for all their work on this. I mean, it's a lot of different moving parts and pieces. I think the benchmarking report is a good start. I think one of the key questions that the board staff lagged that was really good is the return on investment. I think there's opportunity for growth on that. I think there's still some work that can be done to better get at the causal questions that I think we're all wondering about in terms of quality and accountability. But I think it's a good start. So thank you. Great. Thank you. And I'll open it up to public comment via the raise your hand function. Okay. Seeing none. Russ, could you put the motion language back up please? Michelle, do you mind doing that? Thank you. Okay. I'll move that the board hereby determine that one carers fiscal year 23 performance has varied substantially from its 23 budget as approved by the board with respect to the areas of the budget listed on slides 14 through 16, which were included in one carers revised fiscal year 23 budget in which one carer presented to the GMCB. One carer should correct this deficiency by requesting the GMCB amended approval of one carers fiscal year 23 budget. This determination shall be summarized in a letter and sent to one carer from the GMCB. I'll second. All those in favor please say aye. Aye. Aye. Aye. And the motion carries unanimously. And Russ, Marissa, and Michelle, thank you very much for your work on this. It's been a lot. And so we really recognize that and appreciate all that you've done on this. Thank you very much. And I think that is all we have on the agenda today. So I'll turn to any new business or old business. And is there a motion to adjourn? So moved. Second. Second. All those in favor please say aye. Aye. Aye. Aye. Aye. The motion carries and we are adjourned. Everyone have a nice day. Thank you. Thanks.