 Good afternoon, everyone, and welcome to the Green Mountain Care Board. My name is Kevin Mullin, Chair of the Board, and we're going to start this afternoon's meeting. We'll start, as we always do, with the Executive Director's Report, Susan Barrett. Great. Thank you, Chair Mullin. Just a couple of announcements. Please consult our schedule on our meeting schedule on our website for the Barking Dog for the schedule for the rest of the month. It is a very busy meeting and busy month for meetings. We do have a, as in next week, a primary care advisory group meeting scheduled in the evening. And I do think we have a prescription drug technical advisory group. I don't have it in front of me, but Robin, you'll confirm later in the month as well. And that's located again on that press release. So please consult that. I also have, just to reiterate, I've mentioned this pretty much every meeting, but I think it's very important that folks contact. We have an ongoing public comment for a potential subsequent agreement with CMMI for an all-payer model that is located on our website under our special public comment. And that is ongoing. And we encourage folks to please submit any comments regarding a potential subsequent agreement. We will definitely consider those, and most importantly, we'll pass them along to our partners over at AHS and the governor's office, who will be taking the lead in the negotiations on a potential next agreement. And I will turn it back to you, Mr. Chair, I know Mike Barber has some announcements as well. Thank you. Thank you, Susan. Next we'll turn to our general counsel, Mike Barber, to make some announcements regarding insurance rates. Thank you. So I need to announce that two rate decisions by the Green Mountain Care Board and two rate or rate filings, actually. So on February 10th, 2021, Blue Cross Blue Shield of Vermont in the Vermont Health Plan submitted a consolidated rate filing for their large group plans. The filings are projected to affect approximately 5,800 members in 36 groups. After the carrier is corrected in error relating to the development of the administrative charge, the board approved the filing, which is now expected to result in an average premium change of minus 1.7 percent, effective in the third quarter of 2021. Due to the nature of the large group raising formula, the actual rate change for any particular group or even average to cross groups may differ from that expected minus 1.7 percent average change. On February 12th, 2021, MVP Health Plan Inc. submitted a rate filing for its large group point of service riders. These riders are purchased in conjunction with MVP's base large group major medical coverage. There are six members currently with these riders. The filing requested an average proposed rate of minus 3.4 percent, and the board has approved that filing as submitted. And then on May 7th, 2021, Blue Cross, Blue Shield of Vermont, and MVP Health Plan Inc. submitted rate filings for their 2022 individual and small group plans. For 2022, the individual and small group markets are being unmerged, as you know, to take advantage of significantly enhanced federal subsidies that are available under the American Rescue Plan Act to individuals who purchase their insurance through the exchange. Because the markets are being unmerged, the proposed rate changes differ for individual and small group plans. So for small group plans, Blue Cross, Blue Shield of Vermont has proposed a 7.8 percent decrease and MVP has proposed a 5 percent increase. For individual plans, Blue Cross has proposed a 7.9 percent increase and MVP has proposed a 17 percent increase. Again, because of the expanded subsidies that are available to individuals who purchase through Vermont Health Connect, the exchange, these increases will be offset by increased federal subsidies and consumers are encouraged to use Vermont Health Connect's plan comparison tool to understand what subsidies they may be eligible to receive. And representatives from the Department of Vermont Health Access will be presenting to the board on the ARPA subsidies on June 2nd. The filings are currently open for public comment. A public hearing will be held on each filing. The hearing on MVP's filings will be held on July 19th, starting at 8 o'clock in the morning. The hearing on Blue Cross's filing will be held on July 21st, starting at 8 o'clock in the morning. And on July 22nd, the board will hold a public comment forum to hear from Vermonters on the filings. These hearings are expected to take place virtually this year again. And more information on how to participate will be available on the board's website. Thank you, Michael. The next item on the agenda are the minutes of Wednesday, May 5th. Is there a motion? So moved. Second. It's been moved by member Holmes and seconded by member Pelham to approve the minutes of Wednesday, May 5th without any additions, deletions or corrections. Is there any discussion? Hearing none. All those in favor signify by saying aye. Aye. Aye. Aye. We will signify by saying nay, let the records show that they passed unanimously. At this point, I'm going to turn the meeting over to Russ McCracken for discussion on the guidance regarding the ACO executive compensation and a possible vote. Russ. Thank you, Chair Mullen. our discussion from last week regarding some guidance on executive compensation under the ACO oversight rule 5.0. Since last week there's been no public comment, there's no changes to the proposed guidance, and I've not made any changes to the slides here from what we reviewed and discussed last week. This guidance is picking up from our discussion says that an ACO must structure its executive compensation to achieve specific and measurable goals that support the ACO's efforts to reduce cost growth or improve the quality and overall care of enrollees or both, and its guidance under rule 5.203A which is part of the ACO's certification requirements. We had noticed it this week as a possible potential vote and some proposed motion languages included here for the board's consideration. Are there any questions of Russ from the board? Is there any public comment? If not, would a board member wish to make a motion? We approve the interpretive guidance of our rule 5.203A regarding the requirements for the structure of executive compensation in the form presented to us in this presentation. Is there a second? Second. So it's been moved by member Lange and seconded by member Pelham to approve the language as you see on the slide in front of you. Is there any discussion? Hearing none. All those in favor of the motion please signify by saying aye. Aye. Aye. Those opposed signify by saying nay. Let the record show that the motion carried unanimously. At this point we're going to move on to the next agenda item and I'm going to turn the meeting over to Elena Barabee and Marissa Melamed for an introduction to a discussion on the core competency of high performing accountable care organizations. Elena, Marissa. Thank you, Chair Mullen. So I'll introduce our next topic in conjunction with Marissa will lead us through kind of a kickoff of this year's guidance. So we're kind of considering these items together and separately. But I wanted to introduce our guest speaker Michael Baylitz. Following yet last year's ACO budget review cycle. Daffy briefs to think about how we could kind of redirect the conversation and make sure we don't lose sight of the big picture. And so we came to this concept of core competencies. It's a concept that already exists even for ACO. And on the national stage there kind of there's a whole literature around what makes a high performing ACO. So you know we invited Michael Baylitz to help us think through this and to provide his national context and any recommendations he has for how we might incorporate the idea of ACO core competencies into our ACO regulatory process. So we see this as a start to kind of a longer term objective. But we wanted to bring him here today to share the great work that he's done and to help us think through how we might evolve our guidance this year and perhaps next year and and onwards to kind of, you know, capture these elements. So Michael, we'll turn it over to you. Thank you. Welcome Michael. Thank you. Thank you everyone and good afternoon members of the board. Elena, should I pull up my presentation or is someone doing that for me? If you can, just so you can go at your own speed, but we're happy to assist if there's any trouble. So you should have the ability to share. Okay. All right. It's coming up right now. And we see it. Great. All right. That's success. All right. Well, good afternoon again. This is what I'm going to cover in my presentation. I just want to remind you I looked it's been almost a year to the date that I presented to you last. Just as a reminder, we are a health policy consulting firm that helps states maximize health system performance. We've worked in most of the state since our inception 24 years ago. And actually Vermont is one of the very first states that we work with back in 1997. And we've worked with Bishka initially on regulatory oversight of health plans. I'm really back to 2014 with the GMCB first on its ACO pilot and then since then implementation of a regulatory strategy. So I'm going to open by talking a little bit about ACOs in Vermont and the Vermont ACO market because it is the market that is distinctive from other states. And I just want to know how that is the case. And then we can talk later about what implications that has for the work that you do. So I don't think there's another ACO market that looks like Vermont's. That's pretty easy to say. And because of that, you all as the board and the public really apply special scrutiny to the ACO market and you apply your regulatory authority based on the distinctive role of the ACO market. Yet at the same time, the core competencies for an ACO to be successful in Vermont really are not different than they are in any other state. And so I just I want to draw that distinction. ACO, the ACO market in Vermont looks quite different, but to be successful as an ACO really isn't so different. And so I'm going to start by reviewing a few of the distinctive characteristics of one care Vermont. And then I'm going to go through the core competencies that really apply to any ACO in any state. So here's how one care differs from ACOs in the rest of the country. It covers a significant percentage of the state's population. I don't know of any other state that has a single ACO on it, let alone a single statewide ACO. To it has a statewide network of providers. So that in and of itself is unusual to have a statewide network. But but further, I want to know an important characteristic, which is that it's comprised of a large hospital system with many other independent hospitals and other providers. So it's it's a it's a broad network that has lots of independent actors who are part of it. The service area, as you all know, is largely rural. The care management model that one care operates is significantly decentralized. That's different than most ACOs. It participates in a state based primary care initiative in the blueprint and has right from the beginning. That's another distinctive characteristic. It partners with many non medical providers. While that's becoming a little bit more common as ACOs focus upon social risk factors and social determinants of health, it's it's quite it's quite notable that that one care began doing this much earlier and much more broadly than other ACOs have done. Another distinctive characteristic is the attempt to employ global budget arrangements with participating hospitals. Global budget arrangements are not common in the United States. They really are part of public policy in just a few states and they are they're not frequently employed by ACOs as a subcontracting mechanism. And then finally, as you all know, one care and frankly any ACO based on your regulation is actively regulated by the state. I would say probably more so than any other state, although there certainly are some states that are active in the regulation. And and it's subject to a great deal of public scrutiny far more than what one would observe in another state. So these are just some distinctive characteristics and and some of you or some members of the public might might perhaps want to argue some of these points or add additional ones, but these are some of the characteristics that jump out to me. Okay, so before going through the core competencies, I want to share a little bit about what we know about the characteristics of high performing ACOs. I want to acknowledge that while the ACO concept has now been around for a little while, there's not a tremendous amount of rigorous evaluative work that's been done on the effectiveness of them and where it has been done. It leans heavily towards those participating in the Medicare program because the evaluations have been federally funded. Still, there is information that's available and information I think is relevant for you to be aware of and understand. So I want to share a little bit about what we know before talking with you about suggested core competencies. So first, ACOs to date have achieved savings primarily by moving care from lower from higher to lower cost sites and reducing discretionary testing imaging and procedures and higher to lower cost sites, primarily moving people out of hospitals and away from skill nursing facilities. A lot of the focus for ACOs has been on management of high risk patients, but the evidence to date does not show that most savings are coming from management of high risk patients. Again, that's evidence to date and I, as I said earlier, there are some limitations in terms of what we know. There's also information regarding the profile of successful ACOs in terms of their ownership. And the ACOs that have demonstrated the greatest success have been physician led ACOs, not hospital led ACOs. Physician led ACOs in this particular analysis represented a significant number, in fact the greatest number of ACOs and their cost saving strategy has been focused on reducing hospital utilization. They have no economic conflict of interest in pursuing that strategy and so it is easier for them to pursue than a hospital led ACO which can feel self-conflicted because it has both an incentive to fill and empty beds at the same time. And the hospital led ACOs have tended to emphasize reduction in post-acute care costs. It's especially true for Medicare because those post-acute care settings are most heavily used by Medicare beneficiaries. And then finally there are a number of joint hospital physician ACOs that exist and they try to do both, but as I noted the economic incentives are a little bit more confusing and sometimes conflicting for those organizations. So the profile of the most successful ACOs, what we know so far, physician led, they tend to be smaller in size, they have very strong leadership. They tend to have had multiple years of management under risk. There's a lot of evidence it seems to suggest that having a lot of years of managing risk is a predictor of success and they are committed to continuous improvement in quality. So this is what we know so far, I say so far because I think what we will know in the future will be different, but that's what we know so far. The last thing I want to note on characteristics of high performing ACOs is they have to initiate significant change in culture and in delivery of care and this is a super challenging complex undertaking for provider organizations because they really need to redefine what is the business that they're in and how do they go about executing it in really fundamental ways. So I'll just underscore this is hard work. Okay, so this is the feature content I'm going to share today, the ACO core competencies. We identified the set of core competencies at the request of Elena and her colleagues and what we've identified are both structural and operational characteristics of highly performing provider organizations that successfully manage population health. We've grouped the core competencies into five areas and within each there are subcomponents. So I'm going to give you an overview of what we've identified. You might ask well how did you identify these core competencies? Well these are the steps we took. We did a very thorough review of the literature looking at both highly structured evaluations with control groups but also observational studies because there just isn't that much rigorous research to identify in both control studies but in observational studies what seems to be associated with success. We also consulted with subject matter experts and you can see them listed here. One a physician who served as the CMO and Chief Information Officer for a large safety net ACO in Massachusetts and who now directs the population health program for an even larger ACO in the state. We talked with a former CEO of an ACO who was a physician executive and we spoke with the director of Minnesota Medicaid's ACO program. Finally we have conducted a couple of evaluations of Medicaid specifically ACO programs. One for MACPAC which is the advisory body to Congress on Medicaid and CHIP and another for the Robert Wood Johnson Foundation and so we drew more generally from that experience as well. So what I'm going to do now is go through the the five domains that I identified and give you a little bit of information on what would be the core competencies within each and this is obviously an overview presentation. So we start with governance and management and I really want to underscore having strong leadership and strong management is successful. This is true frankly of any type of organization public or private but it's it's also true for a successful ACO and I just think it needs to be underscored because the leadership provides both the the vision and the culture as well as the the excellence in executing on a strategy. And so excellence in governance and management has got to include driving an organization towards a vision of high performance and that means having a clear vision and having a clear strategic plan and and understanding what are going to be the successful levers for generating value because that's what this this business is all about is generating value both in terms of improved population health status and slowing healthcare spending. The successful ACO should have a management team that's highly experienced and that's that's highly skilled and that's that's sort of an essential. There should be communication that's transparent within the organization about the vision and the strategies of the organization and there should be rigorous assessment of financial risk and how to mitigate it. So we start with the governance body and the management team because without strong leadership and competency here it certainly is difficult not impossible to execute on the other core competencies. Second domain we've titled provider engagement and network management. This starts with translating the organization's culture at the governance and leadership level into the delivery system and throughout the network. And as I noted earlier in the case of one care right now this is more challenging because of the breadth of the network and the independence of many of the members of the network. Much more complicated for example than if the ACO was essentially a medical group where every physician was employed. Okay in that case it's easy to communicate message and to execute strategy the communication here to the network is more challenging. So specific elements of this domain are that I want to draw out is developing relationships and holding the network financially accountable for performance. I'm going to come back later on on how best to do this but but having financial accountability that's not just held at the ACO level but also held within the network is important. And this next bullet gets a little bit into how to execute that. What we've observed in best practice organizations is that the network is when it's not just one organization and sometimes even when it is if it's a very large one that the network is deconstructed into local or regional teams. We're at the team level there's leadership and resource allocation and financial accountability. So rather than just holding the whole network accountable there are subunits usually geographically defined within the network that have their own management leadership and their own financial accountability and incentives and disincentives. Third to the extent that there is some choice there's communication of a network of high-performing preferred providers for referrals. In many parts of Vermont there are few choices but where there are choices there is there are differences in terms of value and when I say value I mean both in terms of price and quality and where there is difference and where there is choice that information is conveyed to the network so that care can be directed to where the greatest value can be delivered. And finally there needs to be implementation of value-based payment models with the network and support to providers to transition to it. So I talked earlier about some of the efforts to try to do global budgets with hospitals by one care but the underlying concept here is that there needs to be a payment model that moves away from fee for service. It's what I sometimes refer to as the payment under the payment in an ACO. So the ACO is a payment model and they've got a shared risk arrangement but if the providers that comprise the network are still being paid on a fee for service basis then the payment model really hasn't changed in a fundamental way because the risk is being born at the ACO level but the economic incentives for individual providers who are part of the network remain the same and that has to change over time or the efforts to slow spending growth won't be realized let alone objectives are on quality. The third domain has to do with engagement of the patients who are served by the ACOs and this involves engagement at multiple levels. So it's engagement in governance and in other bodies and the word robust here is purposeful because oftentimes there's a going through the motions effort to involve patients that does not substantively change care delivery and so by robust we mean that this is substantive participation. It should be that a patient experience informs care delivery and improvement in care delivery. There are multiple modalities for engaging patients and certainly during COVID we learned about many new ways and and strengthened our ability to deliver care in new ways. So this is delivering care now virtually electronically in person and multiple ways in all three of those categories. And then finally it's about supporting the network providers to deliver truly patient-centered care and I will say patient centeredness is a term that gets used a lot but not actualized as often. The fourth of the fifth domains is population health management. I have three slides on this topic and I think that speaks to the importance of this domain and I've started here with a quote on from the healthcare transformation task force and emphasizes the need for a complete domain paradigm shift for providers. Traditionally healthcare delivery has been a reactive activity where providers respond to patients who appear and address a need and then discharge the patient. That's not the paradigm for a successful ACO that's doing population health management. It is is much more proactive and continuous and it's it's looking at populations of patients not at individual patients one by one and that's just a profound change. I think that Vermont benefited by having the blueprint for health implemented with primary care practices but that was only with primary care practices. So I think that you can see here it says ACOs need to understand their patient population which certainly involves both patient centered engagement but also heavy use of data and then an application of the data for patient care. Improvement of clinical pathways speaks to the ways in which conditions are managed and pathways suggest that there are standardized ways of care delivery. We have not in our U.S. healthcare system been very good about systematizing healthcare delivery and delivering care the same way that's consistent with evidence-based guidelines but highly effective ACO should be systematizing care delivery while remaining sensitive to patient specific characteristics and then finally engaging the entire care continuum is so that patients are not wandering station to station which as we know many patients with illness experience and and what the ACO should be able to do is bring together the continuum of care so that it is continuous from the patient's experience. So key competencies for ACOs are listed here. The the issue with with everything that's listed on this slide is not doing these activities it's doing them well and I think doing them well is really the the holy grail for ACO performance. There's a great degree of difficulty in exercising these tasks well even in a closed controlled delivery system environment which certainly doesn't exist in Vermont today. So I'm not I'm not going to read through all the bullets here these should be the familiar things to you advanced primary care, addressing the needs of patients with complex needs, addressing social risk factors. So there's there's nothing that's new here but the ability to perform at a high level in all of these areas is challenging. I want to call out at the bottom of the slide one concept that I think is important and this is how to deliver care management. So I'm care management is a term that gets used all sorts of ways across the U.S. Here I'm talking about delivery or supporting the care needs for patients with complex and high intensity needs and the best practice ACOs tend to have a centrally structured program where there are defined protocols for how to do this but with locally embedded care management. So the care management function is close to the practice team and to the patient but it's not a whole bunch of care managers who are all out improvising on their own. It's all to borrow a theatrical reference it's it's a bunch of care managers who are following a script so that there is a strategic consistent application of the care management role and that's hard to pull off again especially hard to pull off in a broad network model that's got the regional spread that's true in Vermont today and all of this supported with a technology platform that provides a tool to the care managers into the practices. The population health program should be also providing support to practice teams to transform the way care is delivered. The blueprint began doing this with primary care practices a long time ago but care transformation needs to occur throughout the network it's not just about primary care. I think too often we put the burden of managing care upon the shoulders of primary care practices alone and that's a mistake. The next step here speaks to standardized protocols these are the clinical pathways I was talking about. Ideally they should be embedded in provider EHRs with notification flags and prompts about adherence to protocols. This is harder to do when the network consists of many different EHR platforms much harder to do and then finally I want to note the bottom here there should be a valuation of opportunities to reduce low value care so these are care this is these are services that don't lend any value to patients and in fact can be harmful and certainly drive up cost. Alright and last managing with data so successful healthcare organizations use technology and quality improvement process improvement techniques to make changes based on use of data and and that's both for driving down spending growth and for improving quality and it means using data at the population level and also at the individual patient level. Those are two very different uses of data but both are essential and both should guide continuous performance improvement activity at the organizational level whole ACO but also within its its component parts. So the practices and hospitals should be using the same types of data tools and quality improvement techniques at the individual level as the ACO might be trying to do systemically. So this is an overview and and just that but but hopefully it gives you a sense of the totality of what any ACO in Vermont should be doing to be successful. This it's in these five areas that the difference between high performance mediocre and low performance plays out and I would argue that from an oversight perspective for the Green Mountain Care Board these are the areas that you should probably be focusing upon the most. So that in mind I want to share just a couple of or a few suggestions for your consideration. So Vermont's made a bigger commitment to an ACO strategy than I think any state and it's therefore appropriate that you have a regulatory structure that's more developed. It's also appropriate that that Diva given its commitment to an ACO strategy's got a major focus on ACO contract management. I believe that the adoption but more importantly the application of ACO core competencies for both regulatory and for purchasing activity by Diva can help you maximize the value of the all-payer ACO model and I have two thoughts on how you might do so and I'm sorry they're both number number one I thought I fixed that but that second number one popped back. So first I think you have the opportunity to apply a set of ACO core competencies that focus on the non-financial functions of an ACO. I know that you've had a lot of focus on the financial functions and it's appropriate to have some focus there but but ultimately it's these non-financial functions that will determine whether one care or any ACO in Vermont is going to be successful over the long term and so with the core competencies I think you can evaluate whether any ACO operating in the state is performing well relative to the core competencies and identify where there might be opportunities for improvement and with those identified opportunities inform your regulatory actions and Diva inform its purchasing actions to drive improved performance in the areas that are critical to success and where you're not getting it right now as a state. And finally I think the core competencies can be used to assess the value that any ACO is delivering to Vermonters and create some transparency around where there may need to be improved performance. The second consideration that I want to offer is that the board would engage subject matter experts who have direct hands-on operational experience leading and managing high performing ACOs to strategically supplement Green Mountain Care Board staff and provide technical expertise and support to periodically assess ACO performance and help you see where you might want to prioritize some of your regulatory oversight activity and to zero in on areas where there's essential opportunity for improvement and where frankly you wouldn't be able to identify the opportunities without that technical expertise because it's too difficult for GMCB staff to do it without having that level of hands-on experience and knowledge. So that's what I've got to present and I would love to invite your reactions and discussion. Thank you Michael. We'll start with the questions or comments from the board board members. I can go ahead and jump in first this is Robin if that's okay with you Kevin. That would be great Robin. Alright hi Michael nice to see you. Hi Robin nice to see you. I had a couple questions. One is on your slide 18 and you had you had talked a little bit about the centrally structured and locally embedded and that's something that I had read about and maybe even talked with you about a long time ago and what's interesting to me about that concept and I think one of our unique challenges is how the ACO and the blueprint fit together because it seems to me like the way we've structured our care management components is that the ACO is providing tools and clinical direction but it's the blueprint that's actually the practices in the community health teams that's doing the hands-on care management and so one of my thoughts and I would love your reaction to this is that culturally it's not only do we need the ACO culturally to be thinking about that we need the blueprint culturally to be thinking about that because we have these two structures that need to work hand in glove and whatever kind of clinical leadership at the ACO level is provided needs to also kind of fit into what's happening at the blueprint. So I just love your reaction to that because I think you know I think our idea there was we don't want to re-duplicate we don't want to duplicate infrastructure we already have right so that makes a lot of sense in a small state but by having these two structures that need to really be hand in glove we've kind of made it harder on ourselves. Yeah exactly and I remember early on the tension between you know not upsetting the blueprint which you know is has a long positive track record and implementing the ACO with the hold at the same time and there was also a lot of tension about giving up local control and autonomy and not having the ACO take everything over. This is a hard a hard issue but I do think that for the care management function to be successful I'll go back to a word I used earlier it has to be more systematized and I think to the extent that these are independent care management initiatives that will be given tools but really are out on their own doing whatever they think is right I think you give up too much. Yeah well that's interesting that's a big cultural change. I know it is and I know that I'm juggling dynamite when I say that I just want to totally acknowledge that that I know that that is it's a highly counter cultural thing to say but I have to imagine that there is some way to find a better melding of the two where there's just not complete and maybe it's not complete but but heavy decentralization the way that is. Well thank you that's that's very interesting. The other question I had was on slide 23 you had some where you were you had some suggestions related to both us and Diva as a payer I was curious if you thought this that the core competency structure could also lend itself well to private payers because of course we have both MVP and Blue Cross Blue Shield doing commercial ACO programs as well as a small self-insured footprint so how to think about beyond just kind of the state government actors how that gets pushed out into the oh sure yeah I mean it seems to me that the that Blue Cross and MVP could probably come together in agreement with GMCB and Diva about core competencies and maybe even a process for assessing performance against the core competencies and to the extent that you could align signals so that if all the players were were signaling the same and partnering the same way on hey here's an area where we really need to get stronger and see some progress that would certainly be more successful than independent efforts. Okay thank you Michael. Yeah thank you Robin. Any other board members? Sure I'll happen. Thanks Jeff. Kevin thank you Michael I appreciate it it's always interesting to hear your perspective and to learn so much from your research on this. I really appreciated the buckets and starting to think about these core competencies and I'm really trying to think about how to operationalize them at the next level in the sense that you know our role is to assess performance relative to let's just say these core competencies and it's important as you said not to just do these activities but to do them well right the ACO has to do them well I think defining well becomes where it gets you know tricky so I think about some of these components about you know you know fostering a value-based culture or ensuring the leadership is experienced and skilled or ensuring that there's a rigorous assessment of risk and a robust consumer participation I'm just thinking about well how do we quantify that what does robust look like what does that mean what is you know a rigorous assessment of risk how do we know that it's rigorous or not you know is there support for transformational how much support is what we need I guess I'm just trying to think about operationalizing in a way that allows us to quantify or something to know whether we're meeting metrics so that or they're meeting metrics so that we know you know along these components there is a high performance level versus just having the checkbox that says yes they have a communication strategy is it an effective communication strategy how do we know so I don't know if you could speak to sort of operationalizing these core competencies in a quantifiable way yeah those are great and totally appropriate questions so this is why my second recommendation was for the board to strategically engage subject matter experts because I don't think that you can actually make that assessment I think it's too difficult but I think that someone who's practiced in the field can look closely at any ACO at how they do things and identify where there are opportunities for improvement in a way that would just be very difficult for green mountain care board staff to do okay and and this is this is a qualitative assessment that does not lend itself to metrics and key performance indicators it's really looking at how the organization is doing its work and it's it's not an assessment that you're going to be doing on a monthly basis it's something you would do you know periodically but it's a deep dive periodically and probably in the areas where there's opportunity you go back and do a deep dive again the next year and in the ones that looked really good you probably don't go and look at them every year that's helpful okay but but if you if you had some people who could compliment the the great team that you've got on staff and could come back to you and say here are the three areas that are of concern that we think you should be focusing on that would give you something that you don't have right now yeah okay um a second kind of area of question a little bit builds on robin's question around centralized decentralized you know care management clinical practices I'm wondering how you what your sense of research and the literature suggests about risk and whether risk you know how risk should be distributed across the network should it be you know there has been a change in our aco's distribution of risk model from a decentralized to more centralized and I'm just wondering how you know what your research suggests optimal risk distribution should be to achieve the kind of delivery system reforms you want to see yeah so you do want it somewhat decentralized but you know there are challenges in doing that first of all providers don't like taking risk right so that's that's that's going to be hard for the aco to pull off and you also have to make sure that when you distribute risk that you do so in a manner that creates both a meaningful incentive and doesn't put anyone's financial viability at stake right and and you've got lots of small providers serving small populations so when you have small ends that means you're going to get all sorts of really bumpy variation in activity big populations work much better for risk than small populations do but you don't have large populations so um I think you want you want to consider uh this is a threading the needle task you do want to push risk down but you want to do so in an appropriate way um and I I have to imagine that it's been difficult for one care to conjole providers to take risk but but if they don't have it I just want to know if they don't have it then their business model is churning volume right that's the problem yeah I guess I was just wondering are their best practices on threading that needle you know given the size of our aco and the size of our sub-populations whether it's at HSA you know is there anything we can learn from where this has been done well and one of the things you said was some of the best performing acos are smaller in size so the size component must have been dealt with managed well in some other you know areas so I'm just I'm kind of wondering are their best practices of what is it what does an ideal risk model look like for to balance all of those countervailing forces that you just suggested yeah so I you know I think um I think you want to start with hospitals and and not with the critical access hospitals but but but you want to start with the hospitals and you would like the hospitals to be on a budget which I think was the initial vision that you know Todd Moore had at the outset that was the right impetus because that's your biggest locus of spend and when I look across the United States and including the other New England states where healthcare spending is growing fastest it's it's hospital services and which is both a mix of utilization outpatient and prices so hospital spending is the first area of concern and then to the extent that there are some high volume specialty practices there's an opportunity to do something there next um this is not a primary care issue and I know there's been an effort to do prospective payment for primary care you do that to help stabilize primary care it's not for managing expenditures that you do that with primary care sure that makes a lot of sense I guess my last question is around um one of the components was around referrals ensuring that there was an identification and communication to high performing providers to ensure that referrals are going to those providers that you know are are high quality and low cost um and so I guess I'm wondering how that's operationalized some of the consequences of that within a network and within a you know provider community particularly if some of our smaller hospitals tend to be higher cost for a whole host of reasons whether that's low volume or other you know you know potential reasons why they might be high cost how do you start to um manage that process because that's that well it's it's even it's also difficult when your low cost options are non hospital based services so you know ambulatory surgery or imaging you could have it done outside of the hospital at way less than in the hospital but the hospital is governing the aco so I mean this is the the conflicting financial incentives issue that I was talking about earlier um uh those are really tough issues and I mean you and you know better than I do the issue of all of Vermont's hospitals um and you know the capacity debate you know that's that is so hard yeah but but you know clearly you know there are opportunities to move the locus of care to lower cost settings yeah and then realizing that it's hard managing and in some ways your core competency would be suggesting that the aco be managing those yeah but I but you know I also want to be fairer with aco I understand that's that's super hard to do I mean the easier thing to do is saying um you know for example I give you the example of patients going to SNFs after hospitals and you know successful acos have saved boatloads of money because they said you know what we don't have to send people to SNFs we can send them home within home supports we save a lot of money so there are a whole bunch of different um care location choices some of them easier some harder but but even in that case the SNF then is losing a bunch of volume right I mean and they're going to come complaining to you that the aco is putting them out of business so that you know the simple this is the old adage you know that someone's health care expenses is someone else's revenue and if you want a slow health care spending we're not even talking about reducing it we're just talking about slowing it um it's going to require some reapportionment of spending in ways that are painful and and people are going to come to you about it right okay thank you I appreciate that yeah thank you jess all the members of the board um I'll jump in here because the the conversation because the conversation that just just had is is the one that's at the top of my mind um you know I I appreciate very much all the work that you did from 2014 to 2017 you know kind of helping Vermont move the ball down the court apparently I wasn't you know didn't didn't have hands on or eyes on that as it happened but I I'm sure that I get from everybody that that that you were helpful and um so you know I look down the road now that I you know can see and you know we have made progress I think especially in putting to putting the infrastructure into play it's not conceptual anymore we have an ACO we have all hospitals involved but grace we have all insurers public and private engaged at some level um some of the FPP for example is is reconciled to fee for service but but they're engaged those contracts are in place we've we've had risk contracts you know with providers but then I look at other statistics like across the hospitals in our last budget process the level of fixed perspective payment in terms of their net present revenue was only a 14 percent and um and and that includes the non real FPP where it gets reconciled and I I feel but I don't know that that's not a level that's going to achieve us the kind of economies and efficiencies that are hoped for back in 2017 and in 2016 yeah and I'm just wondering uh you know the the the tool that seems to me to be the one that will allow us the best to follow the flow of money in the system to see where there are opportunities to save money is price transparency and and we don't have that we have whatever the CMS did with hospitals but um but but the the rest of it is is pretty opaque and so it's hard to kind of like look at this system and say where are the opportunities where there are lower cost providers and and you know I hear anecdotes from folks in primary care or folks in some specialty saying you know if you know we we could compete with UBM medical center for example but they're just so big and uh and it's just not a public issue as to how these prices differential so I'm just wondering you know we are where we are now we've got the infrastructure in play we have 14 15 fixed perspective payment um you know how how do we practically uh you know move and and we have a hospital driven ACO and so you know at the beginning of your presentation where you're talking about moving care from higher cost to lower cost sites aka away from hospitals I just wonder if there's a fatal flaw in this system that somehow we have to correct it um or we're we're not going to be able to to to get the hope for uh benefits that uh that you were looking at in 2017 2018 uh you had a lot there Tom so I'll I'll respond to what what I captured as you were talking first is I think that the penetration rates have to get higher you know 14 isn't enough and I've talked with primary care practices where they said that the percentage of their patients are you know 24 percent 21 percent that's just not enough um to to change the business model uh so even if you come up with or if the ACO comes up with a new payment model if that that's the sole percentage that they're getting through the new payment model and everything else is fee for service it's it's hard to move behavior change at that level um yeah it in terms of having a hospital at ACO it's harder for a hospital at ACO there are many of them and I don't know that it's a fatal flaw but I think it's important to call out that there are some certainly mixed financial incentives that one has that a physician group based one doesn't have uh and there has to be a it has to be a pretty clear strategy that you feel good about to manage around that so that you don't have the ACO not really wanting to empty beds because in fact it's it's bread is better buttered or it's corporate parent breads or bread is better buttered by filled beds and empty beds um and so I I I just think you should be explicit um when engaging with them about that um conflict and what's their strategy for managing that so I wouldn't say you have to blow it up because that's the model uh but I just think it's it's worth calling it out and yeah and taking it on directly whether I'm holding them accountable for finding a way to to manage through it well I I feel that conflict I mean during uh the budget process last year the folks at UVM testified both um at the hearing and in writing that um you know they have this cost structure and it's up to us to figure out how to um abide that cost structure and basically pointed at pointing their finger at the insurance companies but um you know I uh you know I don't think any operation is perfectly efficient and there's always efficiencies that can be found and but I don't know where they are without some kind of a you know a price transparency uh window to to to look to to look for them I mean there are other issues here too there's the cost shift um there's the benchmark plan which I think the state's on a path now to restructure our benchmark plan in in in alignment with our uh um you know healthcare goals but uh I just think that we're at a crossroads we've put the infrastructure in place both at a tactical level but um you moving to the next tier I think is is as you say uh is is going to be a very difficult effort but at least one that we understand is difficult and therefore can um engage ourselves to do it yeah well it was an enormous lift to put up the infrastructure right so I would say now focus on how do you make it work right right because uh it takes a long time to lift up the infrastructure uh and so now I think you just you want to find a way to maximize performance within it right no I I recognize that and you know you have some folks in Vermont that pointed the ACO and say oh it's not effective yet but it didn't exist three years ago you know and putting this infrastructure in place is an accomplishment in and of itself that should be recognized and uh I don't think any practical person expected that in 2018 all of a sudden we would see the benefits of the ACO but now it's reasonable for Vermonters to expect the benefits of the ACO and we have to be pretty clear-eyed about um of figuring out what the moving parts are to move to the next level yeah yeah and you want to see significant substantive improvement in performance yeah okay thank you Jess for asking that question thank you Tom Maureen sure first thank you very much for the presentation it's always very interesting to hear what you have to say and one of the things I want to touch on I think it tags a little onto what Tom was just addressing with the you know penetration but you know we you brought up at the beginning we have one ACO and you know even as we're referring to we talked the ACO and you know I guess are there risks with just having the one ACO in the state and are there barriers to entry as we um continue on the path of only having one ACO I guess you you know do we look at this as that's what we have and and you know we can make that work or you know it's uh it's always interesting to just have the one ACO and and they're doing well and nothing against that but you know I guess from a perspective of someone who looks at a lot of systems how should we think about that or so Maureen your question reminds me years ago when Richard Slusky used to be at the Green Mountain Care Board he turned to me and he said are we crazy for doing this um so when when we did the ACO pilot there were three ACOs in the state and um and two of them obviously um aren't around anymore I don't know that Vermont is big enough to have multiple ACOs at scale um I really don't I mean you know maybe arguably in Chittenden County you could have a couple but you know the the population sizes in the rest of the state are just so small I just I so I don't think um to answer Richard's question from years ago I don't think you're crazy to have only one but if you have only one it's got to be really good okay no thank you that's all I've had but thank you for the presentation thank you Maureen a follow-up but you go ahead first um go ahead Rob and I can wait I'm sorry to interrupt you um just on that same topic Michael um as you just mentioned we the whole conversation about physician versus AC hospital led ACO reminded me that we did have a physician led ACO that was having some good results that basically once the state no longer was paying for the infrastructure with federal dollars um that ACO wasn't able to sustain itself I'm wondering how that works in other states with physician led ACOs like how are they paying for themselves essentially if you know so they yeah so they have to find a way to I mean there are two questions how do they capitalize themselves and then how do they fund their operations so usually um you know through one way or another they find a way to capitalize themselves um and then their operations you know they're self-sustaining they will frequently get care management or infrastructure payments from the payers but those are always netted out when they're reconciling their performance so it really functions as no more than an advance but they become self-sustaining by being able to manage to a budget so it can happen and that that physician based ACO it was pretty small yeah well that was that was my other sort of thought about it is um I wasn't sure if if other in other states where they have large physician practices um I could see how a large physician practice could kind of move forward with an ACO and that was sort of wondering it it seems harder to me when you have a bunch of little yeah relative to other states I mean our large practices we don't have very many of them they're mostly in Chittenden County and relative to other states my impression is that they're still pretty small yeah so I would say it's medical group based ACOs that are um more successful there are IPA models that are a bunch of independent practices strewn together um they're common in California they're huge there but you know I'm coming back to this whole idea of systematizing care delivery and it's so hard to do that if you've got a whole bunch of of independent actors thank you sorry Kevin no problem Rob they Robin they would have to achieve a high level of integration I think in order for it to work Michael using uh the criteria that you've developed as far as trying to assess um high performing ACOs and knowing that one of your recommendations that I heard from you is to seek counsel from people who have been successful successful in the ACO world could you give us the names of a few of what you consider to be high performing ACOs um I can't off the top of my head but I would be happy to provide them afterwards okay that would be great and most importantly what's the significance of the hatchet on the wall uh well I'll show you the hatchet so um this hatchet right here I know if you can see who's inlaid in the hatchet that's George Washington and so this is a hundred year commemoration of his inauguration in 1789 very nice thanks so at this point I'm going to open it up to the public for any public comment members of the public and I do see a hand coming up and we'll start with Mort Wasserman microphone on camera on so um that was a splendid presentation when I first got interested in ACOs because of my background in child health I was interested in pediatric ACOs or ACOs at least that had some children in them and how that would inform what Vermont is doing because we actually have a lot of kids in our ACO because we have Medicaid is such a big chunk and even though the private insurance is much smaller we have Medicaid is a significant portion of our population so I was trying to just find out what other ACOs were mixed like Medicare, Medicaid and private and if I was lucky then which of those had a large rural population because we have 60% of our population live in small counties and what I found out was that I couldn't find out anything and I asked the the head of the folks at at OneCare you know what's what's the you know where's the national database for ACOs and I think this informs some of the questions that the board members have had which is where do we get advice for our situation because we're not going to stand up another ACO we've got one that's going to be very sensitive to its initial conditions so and you don't have to you probably wouldn't be able to answer this question it's very much like uh chair Mullins question but is where do we get advice for our situation where we have to keep rural hospitals open or sacrifice rural communities and we have to keep access and we have to be stuck with a hospital-based ACO structure that we have so maybe a rhetorical question for you well I mean you know there are there are many many states that have rural regions that are way bigger than Vermont and and there are ACOs there and I will say most ACOs in my experience that have been around for more than a couple of years are doing business in Medicare Medicaid and commercial because they need to be doing things the same way for all of their lines of business so being in all three is not unusual I don't think that you're going to find except maybe in Maine examples of ACOs in New England that have a large rural area but if you're willing to look outside of New England then certainly you can find examples okay so I have one more question if I may Kevin if that's okay yep I was astounded that the word social determinants of health did not appear in your presentation yeah it's in my notes as a retired as a retired a provider I hate the word but I'll use it um social determinants are what get people from a primary care situation to an ED and from a from an ED into a hospital I mean there's lots of underlying ailments that require hospitalization but at the margins where you can really affect differences it's the social supports for families that make the difference so how can we weave in and I think we have a good start on this in Vermont by the way the social determinants of health the social circumstances that face families who are covered lives in our ACO yeah so I had on slide 19 a bullet referral practices to community-based services and I wrote social risk factors but I didn't actually read that bullet so what you can do is as a standard practice you can have not just primary care practices but others who encounter patients do social risk factors screening and you can then develop protocols for how to connect those individuals using non-clinician members of the primary care team with community resources which I think is already you know starting to happen in Vermont yeah thank you very much yeah thank you next we'll turn to Rick Dooley right thanks so much and and Michael thanks so much for the presentation as you know I work for health first you know and we obviously have from my collaborative physicians the physician let ACO that we've been speaking of you know and it did close because frankly there just wasn't there weren't the shared savings because what we found is that you know we generally already provide you know provided high quality efficient care and it's hard to you know increase on efficiency when you're already efficient but one thing I just wanted to you know sort of talk about you know when I look at your presentation you said you know physician-led ACO is generally do better than hospital-led predominantly by reducing cost by you know reducing hospital utilization and going to lower sites of care in Vermont we have this really I think a relatively unique situation where we really have a lot of monopoly sort of structures right we have a monopoly ACO a monopoly a large dominant hospital system you know certainly in Chittenden County that sort of is spread out you know we they pretty much have a monopoly on imaging they have monopoly on orthopedic practices there are not a lot of options and when options are raised like the inventory surgery center for example you know the sort of quickly you know the hospital quickly organizes and mobilizes to suppress any you know competition so there aren't any real you know as a as a primary care provider now if I have someone who has an ankle injury I don't have an option within Chittenden County sent to a non-hospital practice I don't have an option for non-hospital imaging I don't want to have really much option for non-hospital treatment if there's a surgery center because they're not doing those at this current surgery center so there are a lot of options to to really drive to lower cost sites of care do you have any experience or are there other areas where they have those same struggles that we do where there just aren't those is the answer that we need more competition or more lower sites lower cost sites of care so we have options to send to because otherwise I'm not sure exactly how how we can do that yeah yeah it's a great question rick I mean I think you have two choices either you create competition or facilitate it at least you can't create it but you facilitate competition by making it easy to get new market entrance or because you have monopolistic players you beef up the role of state government in overseeing the monopoly because though my view is the the role of government is to keep markets functioning and if a market isn't functioning then government has to compensate for that because the because a monopolistic organization is not necessarily going to maximize value for consumers and other stakeholders it's going to do what's in its best interest and I'm not speaking to any Vermont organizations just in general that's what happens and so I think in this particular case if you have only one ACO the green mountain care board has to become very involved in pushing accountability which would include I will say pushing care out of the hospital and expensive settings into lower cost community settings I think it's appropriate for the board to do that either that or make it easier for or make it easy for competition to enter the marketplace do you think the certificate of need program is or the sort of requirement and other states are sort of has gone the the way the wild but not necessarily here yet what do you think that's an impediment to some of this because I feel like it sort of provides a floor for you know a monopolistic entity to come in and say here's why I here's what you know argue against it as it were yeah so it sort of works both ways right that certificate of need keeps you from expanding service capacity where you don't need it and we know that supply drives demand in healthcare but it can also keep lower cost competitors from coming into the market so it's a complex question because it cuts both ways you don't want to add and I will note I mean these are all complicated issues if you bring in a low cost alternative that takes margin out of the hospital then the hospital and again I'm not picking on Vermont hospital this is true any place the hospital is going to look to make up that revenue elsewhere right so right so your net cost may or may not be lower if you introduce a low cost competitor your your system costs which begs the question how much control can you actually have in terms of reducing those costs if you have if you have a hospital that's just making so I find my feeling is that that if you create some budget structure that says we're going to limit how many dollars go into the system then it forces the need to become more efficient because you can't continue to grow your revenue and I it's just my personal opinion but I think that's what the board's got to do because that will create some discipline now there will be some noise then about not being able to attract professionals to come work because we don't pay enough and yes but if you really want to slow healthcare spending growth you have to yet you got to put a cap on growth thank you very much I appreciate it okay is there another public comment and ham davis thank you Kevin this is just a brief comment I was interested in mr ballots a suggestion that you needed to get some expert advice on trying to look at what was actually going on in the delivery field and to try and find out how you might move forward the reality I think it seems to me is that not only is that expertise not available is not available in in the green mountain care board it's also not available in one care vermont if you consider one care vermont to be the 70 people on the water tower hill they don't have any ability to do that either and the and the so the question is really what you do and seems to me that the place that you can make progress is the program you've already started on which is the sustainability effort you just don't have any real numbers inside of that yet I would put that together the idea of getting those numbers and put that together with Michael's suggestion about getting expertise on what the delivery system ought to ought to look at the reality is that when he says well you've got a it's absolutely true that you've got to have you've got to have a cap here but there's a huge cap on here already I mean over the last the the amount of margin that isn't across that's available in within the hospital system the margin is now very close to zero it's underwater in for 2021 and so the cap really is the cap really is in place and the question is seems to me is that you would have to really figure out is what what you want to what you want your system to look like in terms of the way that the medical care is delivered you have to figure that out first then you can have to you're going to have to figure out how to pay for it but I don't think that you can get it the I don't I don't think you can get it I don't think you're on the track to get it I just don't see any how you're going to do that thank you thanks ham just remind people that the chat function isn't a way for public comment in that if you have something meaningful to say to please say so in during this public comment period and to be respectful when you use the chat function so is there other public comment hey Kevin it's Walter on the iPhone hey Walter oh yeah yeah I'm at work I couldn't get on nice presentation say thanks I wanted to kind of pick up on something that Tom said earlier when he's talking about the benefits of the ACO and I'm curious what are the benefits of the ACO and then the presenter and I've got tractors going around in my ears so I couldn't hear his name as they're working on the working on some construction but the role of government is not just to work on the free market or break up monopolies or whatever but the role of government is a lot more than that and it's not just to maintain a free market whatever free market is because they're never free anyway that's my comment sorry if you heard traffic in the background I know you came through very clearly Walter thank you thanks Kevin is there other public comment hearing none I wish to thank you Michael it was a great conversation and a lot to chew on so thank you very much thank you nice to be with all of you and at this point I'm going to turn the meeting back over to Elena and Marissa as we continue the conversation and discuss 2022 ACO guidance and and really debrief 2021 so Elena Marissa hi thank you chair Mullen can you hear me okay we can great I'm gonna go ahead and share my screen just a minute okay can you see the slide yes yes okay great thank you so my name is Marissa Melamed I'm associate director for health care policy I'm here with Elena Baraby as well who introduced us and we're going to continue this conversation as a debrief of our 2021 ACO budget and certification oversight process as well as a kickoff for 2022 season we're quite thankful to Michael Baylett for being here again this year it is really helpful to have this conversation in the national context as we contemplate the new budget guidance and new budget review season so hopefully we can weave some of that conversation into the discussion today Michael I can't remember if you're able to stick around or not if you are that and you have anything to add that's great and if not we can always bring follow-up questions that are relevant to Michael's talk that may may come up during this discussion as well so with that I'm going to proceed let me get this into a better view for you all right so our agenda for today we've been through on numbers one and two and now we're going to talk about the debrief and FY 22 kickoff so here's an overview of our approach to the 2022 budget review we're going to talk a little bit about process priorities and outcomes for our budget process for 2022 the process included or continues to include a stakeholder review of that include both debrief of our 2021 process as well as we are about to and embark on stakeholder review of guidance that we're formulating for 2022 also consists of quite a bit of internal collaboration among green mountain care board teams or green or or green mountain care board regulatory processes particularly overlap with hospital budgets and rate review to better align these processes as well as a collaboration with other state agencies and the process also includes public and board input so we bring this discussion to the public as we're doing here today to hear from board members and to hear public input priorities that have been identified through the process so far that we kind of use as our overarching framing number one our ACO financial and quality performance we are you know continually looking to improve how we measure and understand their performance in the context of our statute and rule and oversight and you know as you heard from Michael today that's partially why we brought him here and what this is all about priorities also include continuous improvement in having our analyses and decisions be data driven regulatory alignments as I mentioned across other regulatory oversight processes with the board and we are working toward more standard reporting and templates including metrics and definitions where appropriate to help us carry the review year over year and understand across the full landscape outcomes from this process are twofold since the adoption of the FY 21 budget order we have been working on an ACO reporting manual which as you'll recall was budget or condition number one the goal here is that we collect standard reports on the performance year year over year these reports include things like the ACO's network development strategy clinical focus areas population health and quality improvement reporting quarterly financial reporting complaints and grievances and member communications and other specific reporting on things such as the comprehensive payment reform program addressing childhood adverse events also other ad hoc or one-time reports requested by the budget order so these things we have found are you know becoming more standard year over year they've traditionally been in the budget order but if we want to continue to collect them it makes them it makes more sense to have them put into a central reporting manual so we have been working on that in the off season the goal here eventually is to allow the budget submission to be more about the budget year so what are the assumptions that are being built into the budget so that it can be forward-looking and not so much performance year reporting so we're trying to to have more clear reporting throughout the year so that when we get to the budget it's forward-looking this isn't going to happen just in one year I think it's going to take more time than just this year to have it separated in that way but that's sort of the the goal that we've been working toward to make this process more clear throughout the year so the other outcome of this process is of course the final guidance for FY 22 which today is the kickoff we will be working on it throughout the spring we will bring drafts of that guidance to the board in June so that it can be reviewed and adopted by the end of June and posted by July 1 I think I got ahead of myself that that timeline is here on this on this slide where at May 12th on June 9th you will hear you will see the first public presentation of the guidance and then there will be some more time for public comment another draft with any changes and a vote hopefully on June 23rd but at least by the end of June so that it can be posted by July 1 to allow one care to prepare their submission for October just a reminder here on the slide 6 the statutory authority when we prepare the budget guidance and the certification form we review it against the criteria that's set forth under this authority and that consists of the standards and requirements under 18 BSA 93 82 oversight of accountable care organizations green mount care board rule 5.0 and the all-payer model agreement we spend a lot of time cross-checking what goes into the guidance and what goes into the form with the criteria that's laid out in the statute of the rule to make sure that we are covering all those areas. As I've discussed as your call through the budget review process this criteria is quite broad and so one of the benefits we felt from having Michael Baylett present on core competencies is to help us kind of put a framework around that and so Michael and his colleague Aaron did also do a little work kind of mapping that to the criteria so that we can make sure it aligns so that if we do or if we are able to adopt that framework into our review we know that there's a sort of a clear alignment to what we're required to review under the statute. Slide 7 is an overview of our debrief discussions from the FY 21 process so we had discussions with one care as well as the office of the health care advocate and then our green mount care boards or staff teams that work on ACO oversight to try to understand you know what how things went what could be done better what we can bring forward into the next process and here's a here's a summary of what what we came up with. With our discussion with one care the highlights included improvement in regulatory and contractual alignment so again this is understanding how the ACO process overlaps and aligns with our hospital budget process or rate review process but also recognizing that one care has contractual agreements with the payers and oversight by department of Vermont health access and Medicaid and so we were working to understand those requirements as well so that it can be aligned. In addition we've done work with one care on business process alignment so understanding when during the year certain things happen so that we are aligning our deadlines with when things happen in their contracting cycle and the third kind of piece that fits in there is template alignment so where they report to payers or where they report under other contracts we're working to align those reporting templates and all of these three things to these things together regulatory contractual alignment business process alignment and template alignment we believe is leading to administrative reducing administrative burden and regulatory burden on reporting. It's I will admit it's quite a lot of work to sort of get there in working toward this alignment but the the goal I think will make things cleaner and better aligned and ultimately reduce burden and improve the reporting. We also discussed with one care ways to improve the narrative portion of their budget submission in particular providing rationale for changes that are being made discussing the why and so those those are ongoing discussions to try to get at improve narrative as Michael Baylet said as well not everything can be reduced to a metric or a key performance indicator there has to be a substantive discussion particularly about non-financial programs and changes there and so working together to sort of improve that narrative is a priority. Transparency of course as well making sure that the the correspondence on the deliverables what is due when what comes in making sure those are posted so that members of the public can see them is a priority as well as evolving business model and strategic planning discussion of strengths this is opportunities and threats we know that one care is undergoing a strategic planning process that is a priority so that is something that we look forward to seeing in this coming process as well. Our discussion with the healthcare advocate I pulled out sort of three bullets here we've been working with them towards a collaborative and transparent question and response period as you know the healthcare advocate has a role in questioning the ACO and reviewing their materials as well we've worked with them closely over the past couple of years to improve that question and answer period so that our questions are aligned as well as they have the ability to ask questions that are particular relevance or importance to their work and I think that we have made some improvement there and will continue that process. We've also discussed with the office of the healthcare advocate ways to improve interpretation of data trends over time particularly in light of the COVID-19 disruption over this past year we know that is will you know have a big effect on how performance metrics are you know interpreted and reported or not reported in some cases and so we were working with them and how best to interpret that data because it's it's the reality and also elevating the public comment and the consumer experience of being in the ACO is a priority that comes out of our discussions with the healthcare advocate and we want to make sure that that you know we're able to incorporate that into our process to the best to the best we are able. The things down at the bottom under Green Mountain Care Board these are some of our discussions that we've had among the processes within the Green Mountain Care Board they include things I've already mentioned improving regulatory alignment working towards standard reporting metrics and definitions data driven analysis and decision making collaborating across teams as well as agencies improving transparency as well as incorporating where appropriate expert consultation and again that is is illustrated by having Michael bail it with us today and you know as we go forward considering how we can best use expert consultation to improve on our oversight and evaluation of the ACO. So this is the frame within which we are going into our 2022 budget season so this slide has a lot of words on it but let me describe what we are doing here. So first of all the FY22 guidance will be based off of the FY21 outline this makes sense because the FY21 guidance was prepared in the context of the public health emergency which we are still in and still dealing with progress was made on all of the goals that we set out to achieve in 2021 and that progress will carry forward so you'll see here are the slides that I already mentioned or sorry the priorities that I already mentioned at the top of this slide. In 2021 we identified the goals that you see on the left there and like I said there has been a lot of progress which I've already discussed somewhat made on those goals a lot of them will you know carry forward. You know for example making sure to break out information requests across processes categorically to ensure rule five regulatory requirements obviously we're going to continue to do that emphasizing data over narrative where we can while also improving the narrative streamlining our information requests across the regulated entities these are things that we've been working on and plan to continue to work on. I don't need to name them all. I will say so last year the staff reduced guidance with the goals of increasing transparency reducing administrative burden while helping the board and the public understand how the ACO is adapting its operations given the COVID-19 public health emergency and the reduced ability of hospitals to take on financial risk. This year the question around COVID-19 impact and the public health emergency is perhaps a little bit different. The ACO is a year into adapting its operations around the new normal for providers so our question is how do we shape this year's guidance around the current state of the pandemic questions such as what was put on hold that might be reengaged what are the impacts on provider network and capacity how has the public health emergency affected performance or what impact does the ACO anticipate this might have on performance what is the impact of reduced care overall in 2021 so that is a question that we do want to hopefully discuss and maybe hear some input on this year how does how does the COVID-19 apply to the ACO in the 2022 budget guidance this is something we'd like to hear sort of weigh in on last year it was a little bit more around reducing administrative burden I think this year it's probably more around understanding impact but we would like some input on that we would also like some input on how you would like to incorporate the core competencies that Michael Bailey discussed into the guidance and review is that something you know to what level do we have the ability to incorporate that this year and we can we can see what we can do or how we could make a plan to incorporate it over time other things other issues that might apply that are happening and other processes with the board include hospital sustainability work as well as a reminder that 2022 is the last year of the current all-payer model agreement so does that factor into our guidance this year and in what way we can come back to that you know during the discussion if we need to for reference but I'll complete my remarks just by sort of reminding you of what the two pieces of guidance look like so this is last year's 2021 certification eligibility verification outline just as a reminder certification is a one-time thing that happens which one care was certified in 2018 however they are required to sort of renew or we call it verify their eligibility for certification each year and what that looks like is a form that we create that they fill out giving us updated policies and procedures that allow us to check that they still meet the requirements of certification we also ask questions you know specific to certification requirements that we want to look at in more detail for example the interpretive guidance that you heard about from Russ will be incorporated into the certification this year so we're in the process of putting together that form which will also be reviewed and completed by July one and then the FY 21 ACL budget guidance this was the table of contents there were eight sections that we collected data and narrative on currently the current draft that we're working on uses these same sections with small tweaks for things that you know we're discussing now or want to hear from today hear from you today about changes that we can make actually I guess before public comment there'd be questions from the board but this is our overview for today I don't know if Elena wants to make any other remarks or we can just go directly to board member questions or feedback on anything that you've heard today and how you'd like that incorporated into the guidance and we will take your feedback and as well as we can take public comment today on any input that the public would like to give it to the guidance okay I think we can go right into discussion if you're ready chair mullen I am go ahead board members well this is Robin I'll go ahead and jump in and so I think you're right Marissa that I'll just start with the questions that you asked for some feedback on that the question around COVID-19 is different this year and I think having an understanding of we certainly heard in last year's discussion and testimony about different programs that were not expected to be as robust or put on hold due to the pandemic and the limited capacity for provider organizations to work on quality improvement and delivery change so I think having an understanding of where people are at certainly when we were doing the hospital budget guidance we heard from regulated entities in that process that there was a substantial amount of fatigue at the per individual provider level due to the stresses and frequent operational shifts due to COVID-19 so having an understanding of how that will impact the ACO's progress and performance would be good I wonder if also there's an opportunity to hear a little bit about lessons learned and areas of performance that could be strengthened moving forward I think we usually try to get at that pretty much every year but given that 22 is the last year of the current agreement it would be good to hear that now and then lastly on the core competencies one thing I'm I'm wondering if you may have already discussed with Michael or at the staff level is what I heard Michael suggest was a deeper qualitative dive that was not necessarily an annual process but a periodic process and I'm wondering if that fits better conceptually into certification in terms of you know maybe in addition to understanding and certification which pieces have changed doing that more qualitative dive in different aspects so that's just a question not for an answer necessarily today but I guess having a sense of whether those five domains whether they fit more in certification versus budget would be helpful to me I think we have some work to do to take the high level concepts and drill them down into actionable regulatory items I know certainly one thing that we've been working on improving in our process every year is ensuring that that our background or backup material for each of the statutory requirements is clear and that we're receiving that so I think with qualitative stuff it can be a little bit tough to figure out how to document that so I think for me I I would want us to take the time that we need to figure out to just this question to Michael how to really operationalize that in a meaningful way and not necessarily rush to restructure the guidance this particular year those are my thoughts thank you Robin other members of the board okay we're going to open it up for public comment is there any public comment hearing none we're going to move on I think that people must be looking forward to the 2019 expenditure analysis and we're going to go right to that so Laurie Perry thank you Marissa thank you Elena Laurie sure you see my screen um we can see a picture of you okay hold on tell me are the slides it is a slide yeah thank you um thank you mr chair and I will be presenting with David Glavin he's going to have a few slides to show you on our interactive visualization so this presentation is the 2019 Vermont health care expenditure analysis um these are the topics I will be covering today the interactive as I mentioned David will cover that I'll give you a summary of what happened in the expenditure analysis we'll talk about what's the relationship of the expenditure analysis to the all-payer model hospital budgets and insurance rates then I'll dive deeper into the Vermont resident analysis showing you the spending and growth and then how do we compare it to CMS's nhe accounts then into the Vermont provider analysis and I'll show you the revenue growth from the different providers hospital and position revenues the midi migration of hospital inpatient discharges and show you the comparison of the resident analysis to the provider analysis and why they're different and then um the part of our statute is to give a projection for fiscal year 19 through 2020 and then further on into the slide deck we have an appendix that has more documents and methodologies for your review um the health care expenditure analysis has been in statute of some form another since 91 we've been doing it um either under bisca or dfr and now the green mount care board is responsible for presenting the expenditure analysis this report is consistent um that's why some people value it more because of the consistency and we examine the trends in spending the sources of funds we analyze broad sectors of provider and facilities like hospitals physicians mental health home health and pharmacy and we also look at the payers that are paying for those services such as medicare medicaid commercial payers self insured and hmo's we quantify the spending for all these services provided by vermont residents and non-residents and for the services provided by vermont providers to ours to these out-of-staters and also um we have um services to vermonters that are outside of vermont this um data or this analysis relies on the integrity of the information collected directly from the payers and the providers in some cases it's very limited so we have estimates such as for independent physician revenues and out-of-pocket this report compares vermont data to the national data we see from cms and we use the health consumption expenditures instead of the health health expenditures because we don't have information on spending for investments research structures and equipment like the federal government does and now i'd like to present david clavin are you there david you know i have a tendency to do this all the time thanks lori i was like i was on mute i gotta make sure that i'm presenting when i present because i'll i'll start into the presentation and nobody will be able to see anything so i definitely will call out prior to doing that um i just want to say hi to everyone thanks thank you lori for um for the introduction and i'm just going to cover um just two elements i want to discuss our um our new access to the to the reports on something that we're trying to update and i want to i've spoken about this in previous board meetings but i just want to um bring light to it again and with that i'm going to go ahead and share my screen at this point and let me know if everybody can see the screen now okay great so um one of the things that we're trying to do is make access to our reports a lot easier and more streamlined um you know the and this is not just for the interactive visualizations or interactive reports this is also for the general reports of course the gmcb produces um many reports during the course of the year and of course over time and so what we want to try to do is um is drive traffic to those reports and so part of that is is this layout that we've we've now created here um this one is for the expenditure analysis in particular and what we kind of think of this is one stop shopping um this i also want to point out this is um and this is very important is that this particular page is just for the resident perspective of the expenditure analysis we're hoping down the road to provide the or to develop a the provider perspective as well um in both an interactive window and also um and also just as the report page as part of the report general report page for the expenditure analysis um but like i said this is a kind of one stop shopping where we do and we've laid it out so that we have um the data elements are here that are used to generate the report they're available to the public um in addition to that all of the supporting documentation and this is uh or for this particular for this report the report itself the manual and then a link to the historic read or previous reports um and this is going to be consistent through um we're trying to make this consistent throughout all of our reporting pages um and so the next piece of this i want to highlight is actually the interactive window or the interactive interactive report itself one of the elements that we have are one of the things that we've incorporated into the into the page now um in the past um we've had to work we have we have been publishing our reports um through a third party vendor that we use i don't want to even call the vendor but just through a third party public resource where the reports reside in the past you've had to click on a hyperlink that would take you to that um report page one of the things we wanted to do is make it very easy so that you didn't feel like you were leaving the gmcb um webpage and so that the report now launches um directly from what we call a modal box and so you never actually leave the website itself and you access the report right away i've actually got this pre-open to the second slide but there are um an assortment of slides here i'm going to expand this in just a second just to let folks know that there's a there are tabs that have different types of analyses and different um overviews of the analyses across the top here um so very quickly one of the things that we do encourage people to do is go to the full screen mode and i'm actually going to zoom in a little bit i think we've tested this um hoping folks can see that a lot better um so just a few things that we've updated in this particular report trying to make it a little bit cleaner a little bit more a lot more user friendly hopefully i've added a few elements in in terms of how to use the dashboard dashboard which you didn't have before or they were sort of um they were kind of hidden inside of these what we call tooltips when you hover over particular bars it gives you some instruction um and without going into too much detail i think people are very familiar with the interactive reports but or with interactive reports in general we see them in the new york times and all you know you see them online and websites so you know we have filter elements and this was on all the pages in addition to that these bars as well provide filter elements over here for these area charts which provide a visual distribution of each independent provider for a particular year um and i want to just make a very important clarification about the interactive reports these are not a replacement or a you know obviously not a replacement for the main report report itself these are this is a supplement to the report and we think of this as a i like to think of it as a consolidation of the data elements and supporting graphs and tables and charts that lory has developed for people to quickly be able to access the report data elements and not have to dig through the more formal report write up to find these charts so so this is these these interactive reports are a supplement and they're they're really they're really to be used in conjunction with the supporting material including the report and the manual as well so i want to encourage people as they go through these to put the visualization elements in the context of the report itself i believe lory has a hyperlink to the reports page built into the slide deck that has been sent out so i'll let people go ahead and pursue that at their own leisure and if there are any comments we we encourage people to provide comments back on any way that we can improve these reports for general generally users especially for the public which is the primary goal or is the primary focus for these reports to provide that open and transparent access to our data and to the reports themselves for the public and with that i'm going to go ahead and turn the the rest of expenditure analysis back over to lory actually i want to i want to give a shout out to one of my co-workers jessica and disabelle who is responsible for actually developing these pages putting these pages together and doing the code behind the pages the web page to to create this much cleaner look and easier accessible look for everyone and lory it is all yours i'll stop sharing now if i can find the stop sharing can you see my slide just the same page yes okay down at the bottom of that page that is in the presentation is the link to what david just showed us so if you wanted to link to from this presentation so this was what david just showed us but it's in the slide deck and so now i'll go on to the summary of the report um for the resident analysis i found that the vermont spending increased 4.1 percent from 2018 and this was um higher because 2018 you had an increase of 1.9 percent from 2017 the average increase for the period 2014 through 19 was 3.3 percent i found that commercial insurance spending increased 3.7 percent and it seemed as if it was more mainly from hospitals drugs and supplies physicians and other unclassified the um categories that decreased was admin and net cost of health insurance and other professionals Medicare spending increased 6.3 percent and this was seen in drugs and supplies home health other unclassified and physicians and then there was decreases in nursing homes and hospitals Medicaid spending increased 2.9 percent and as expected increases were in mental health and other government activities hospitals nursing homes but decreases in physicians and admin net cost of health insurance i like to bring two people's attention that this are at the bottom of certain slides mean it's looking at the resident analysis data and it'll change when you want to see provider analysis data um then we show the vermont compared to the united states cms data and as i just mentioned for vermont it increased 4.1 percent for spending compared to 2018 the united states increased 4.5 percent and i was using health consumption spending the um the united states increased 4.7 percent from 2017 to 18 so this was a slightly less for the united states on a per capita basis or per person vermont is 10,442 dollars and this was an increase of 4.5 percent from 18 the united states was um at a lower per capita of 10,000 i mean we were lower than the united states and that was 10,967 um when we compare the gross domestic product vermont is at 19.2 percent in health care and the united states is 16.8 percent um when we look at the provider analysis we are looking at the health service revenues that the providers received for in and out of state patients and this increased 5.7 percent in 2019 and this was an average annual increase of 4.2 percent for the period 2014 through 2019 we saw growth in hospitals increased 4.2 percent and this quick category includes the hospital employed physicians the other categories that saw increases now this is just increases is 25 percent for vision and dme drugs was 11.8 percent and which includes supplies and then other licensed professionals was 6.7 percent nursing homes was 5.8 percent dentists 4.6 and home health 3.4 then physicians 1.7 um i'd like to point out that this all was before the pandemic so it'll be interesting to see what's going to be happening in fiscal years 20 and 21 compared to this 19 data we like we wanted to give you an idea or to the differences between the expenditure analysis and the all-payer model total cost of care so um the expenditure analysis on the resident side is for all residents where the total cost of care is only 75 5 percent of the residents because it excludes people who don't have insurance like uninsured and then also pairs that are not in the all-payer claims database the other uh difference is this is the expenditure analysis based on health consumption where the total cost of care all-payer model is 46 percent of the health consumption expenditures and this is limited to medical claims for services that are similar to or covered by medicare parts a and b and non-claims payments from primary care in the expenditure analysis i include medicare advantage within medicare because that's where the medicare beneficiary is where in the total cost of care all-payer model it is included in the commercial payer the expenditure analysis versus the hospital budgets um the expenditure analysis shows all the hospitals which includes bravo retreat the community hospitals and vermont physician care hospitals gremount care board only regulates the 14 community hospitals and the expenditure analysis is for calendar year 2019 and then the hospital budgets are for federal fiscal year 2019 so we have differences little differences but we don't usually correct for that and then the expenditure analysis includes all the financial information associated with the facilities so for instance i'm taking into consideration net patient revenue plus other operating revenue for the hospitals on the hospital budget side we're only regulating basically the net patient revenue and we try and do that through commercial charges the expenditure analysis when you compare it to the insurance rate review is that we in the expenditure analysis i include all commercial plans which even include workers comp the insurance rate review is only limited to qualified health plans and fully insured products based in vermont the expenditure analysis like is up for the calendar year 2019 where the 2019 medical expenditures are used for this last year's estimate for premiums for 2020-21 in the insurance rate review process the expenditures for the expenditure analysis includes all of the expenditures for for monitors for even their services that are outside of vermont too but also the expenditure analysis includes vermont providers that include providing services to out-of-state patients where the insurance rate review is only for plans that are for vermont residents that are not necessary for vermont residents but may be having an employer within vermont so into the growth for the 2019 resident analysis this slide is showing the payers on the top from 2014 to 2019 and in the bottom section is the providers and facilities for 2014 through 19 so when i mentioned the growth from 18 to 19 is 4.1 percent you see it matches up and then the average annual change from 14 to 19 is 3.3 percent um the i show this slide to just kind of emphasize the change from 2000 that one was 2014 to 19 this is 2011 to 19 and the drastic the quid the change is in 2011 we were five billion and now we're at 6.5 billion and the average annual increase was 3.4 percent for this time period and where i'm again i'm mentioning that the change between 18 and 19 is 4.1 percent so showing you the dollars and the percentage change on the slide these are the individual categories and the total of the spending for in and out-of-state spending for vermonters and hospitals are the highest as expected and other unclassified would be the low but this slide slide 15 was showing what is what was the categories that increased so i saw that drugs and supplies was a big category that increased this year and it was mainly from medicare and commercial insurance and then out-of-pocket hospitals were the next they increased in the commercial pairs and out-of-pocket and then medicare notice i don't say medicare um medic mental health and other government activities as expected is from medicare and then the other unclassified i mainly saw those increased in commercial and medicare and then home health increased in medicare and out-of-pocket this slide is showing you that maybe like commercial was 33 percent of the total spending for 2019 but they made up 50 percent of the enrollment for medicare 24 percent of the spending for the 2019 but medicare was 23 percent of enrollment and that's what this slide is trying to show you then um i try and show you where is the funding coming from which is the top pie charts and then where is it going so you can try and match up these as best as you can this is also a slide that the cms was using also similar so i tried to use it for what we have in vermont residence analysis so i'm going into slide 18 and starting the commercial insurance pair where i saw the spending increase in the different changes so for commercial insurance that increased 75.2 million dollars or 3.7 percent and it was 2.1 billion of the total spending and most of this was in hospitals drugs and supplies and other unclassified and then physicians but then i saw decreases a large decreases were in admin and net cost of health insurance and other professionals so you can see that down at the bottom here and then at the top the we'd like to find out where is commercial resident commercial um spenders or our residents where they having their care and i found that it was 75 percent previously now it's only 72 percent within vermont and that i saw that the commercial enrollment decreased a 0.4 percent from 2018 so it's now 313,605 of course these are estimates also the medicare was increased 9.95.1 million or 6.3 percent and this makes up 1.6 billion for total spending and i mainly saw the increases in drugs and supplies and a big thing in this particular category is i'm seeing a lot of supplies and we're going to be investigating that more and more because that that is really hard to understand and we're going to be investigating it more we understand drugs because we've also been hearing about that from the hospitals and pharmaceuticals that it's increasing so for medicare we also saw increases in other unclassified home health physicians other professionals and then their admin net cost of health insurance but i saw decreases in which i was a little surprised in nursing homes and hospitals and dentists the in-state spending for medicare remained at about the same at 73 percent from previous years and then the enrollment increased to 141,895 or 3.9 percent from 2018. Medicaid increased 49.1 million or 2.9 and this was a total of 1.7 billion for total spending in vermont for 2019 and i saw as expected increases in mental health and other government activities hospitals nursing homes and other professionals and some in and other professionals excuse me this is wrong where it says home health spending decreased in physicians admin net cost of insurance but i'm seeing a decrease in home health drugs and supplies because they also are showing rebates in the drugs and supplies here and of course as we expect medicare has 86 percent of their spending is with vermont providers and medicare enrollment decreased this year 148,689 or 4 percent from 18. This slide i've try and show because it's such a big category mental health and other government health activities is to show that it's mainly in most of spending is in mental health clinic and community rehab treatment day treatment then they have categories called home and community based care such as age and disabled enhanced residential care and assistive community care so these are the increases that we saw for those type of categories but i did see decreases in managed care organizations and then the other mental health and substance abuse services and again this is for 2019 this slide is showing the net admin net cost of insurance and i found through the years that the surpluses for the change in their surpluses for the insurers commercial insurance is what causes a lot of this swing in the last few years and you can also see on the bottom slide we're trying to show you what makes up that net cost of health insurance for commercial payers and the gray part is the change in their surplus so these these categories can usually be one step it's it's like their investments it's their changes in their reserves it's their taxes it can also be some of the aca fees can cause some of these changes so um just wanted to give it in context whenever you see these changes in net um admin and net cost of health insurance but we'll also see some of these swings in the other government payers the um health care analysis i try and show what happened in 2014 and 19 where the payers what shifted and i saw that commercial insurance paid 35 percent in 2014 we're in 2019 it was 33 percent of the spending in um this one was a quite a shift with 21 percent in medicare in 2014 now it's 25 percent and we we're we realize that because the medicare population in our um aging population this one is showing then what is what has changed in the provider categories from 2014 to 2019 so our hospitals with 37 percent in 2014 and they dropped a little bit to 36 percent in 2019 and i found that drugs was 12 percent drugs and supplies was 12 and 14 and now it's 15 in 19 and i bet it's going to be even more in the next few years this slide is showing by the um provider service categories who is making up most of the spending is it government funding or is it private funding and private funding also includes out of pocket so as expected mental health and other government activities is mainly medicaid and state government and some federal and for the dentist you would expect it to be private um commercial insurers and out of pocket so this is just a quite a contrast of where public payers versus private are um funding different categories now i'm transitioning into the national health expenditure accounts compared to Vermont residents expenditures and this year i found um when i wanted to compare what i had previously mentioned into the 2018 expenditure analysis that things had changed so i went researching and i found that the nhe every five years they do a comprehensive revision so um that is because of the census and other information that they have been able to obtain to change their estimates and everything like that i noticed they changed how the rebates were counted for in drugs and supplies and i saw a little bit of changes in hospitals so that's why i mentioned this is because i thought that any researchers should take caution when they want to look back at some of the previous expenditure analysis compared to what i'm showing this year for those same years and uh this is where we want to emphasize what is happening in the national health expenditures what categories are measured each year what's the type of data that is being used and then to emphasize that the cms does a state health expenditures but it's only every five years and when you compare Vermont to those we have we have more detail we have when we are using the national consumption expenditures instead of the national health expenditure which is at the higher categories so this is emphasizing that again we're using this middle line this middle bar because we don't have investments in research structures and equipment or currently we don't so this slide is showing you if you take the health consumption expenditures and the federal government increased 4.5 percent Vermont in comparison increased 4.1 percent and then the per capita for um the united states is 10,967 Vermont is 10,442 this united states increased 4 percent and we increased 4.5 percent and then Vermont gross domestic product as a percentage excuse me healthcare as a percentage of gross domestic product is 19.2 percent and the united states is 16.8 percent we are also more generous in our Medicaid and that's part of the reason why we are higher than the average in the cms calculations um this one is just another look um people want to see this back in time so this is showing from 2010 to 2019 in the different categories of um expenditure the different looks that this one is showing the spending growth over time from 2011 to 2019 um Vermont versus the united states Vermont is the darker line and the united states is the light blue and I want to emphasize as you'll see in all these slides I'm using health consumption expenditures so um in 2019 Vermont's per capita as I've mentioned growth of 4.5 percent was more than the 3.5 percent average increase from 2011 to 2019 the us per capita growth of 4 percent is um was a slight 0.1 percent more than their 3.9 percent average in increase for the same time period of 2011 to 2019 another look at per capita so you could see the actual dollars per capita and then this one is the gross state product a gross domestic product and um give it from 1996 to 2019 if you had a pre if you had picked up the previous slide or what we gave you previously excuse me I had to update this this morning it wasn't taking into 2019 then the provider analysis again this is patients coming to Vermont and we're using Vermont providers so this is Vermont providers revenues where what payers are they receiving their revenues from and then this is the providers who increase or or um which ones make up most of the revenues received during the different years so this year it increased 5.6 percent from 2018 and it was 4.2 percent average annual change from 2014 to 2019 the revenues increased five from five billion in 2010 to 6.8 billion in 2019 this was an average increase of 3.9 percent and this was like I just mentioned previously is 5.6 percent increase from 2018 this slide is showing the total dollars of spending by provider category and then also showing it what is it make up in the percentage of the pie in the total spending so as we've always said hospitals is 46 percent of the pie and this is all the hospitals in this particular category and drugs and supplies is 15 percent this slide is showing I wanted to show hospital physician revenues so of the 2018 physician census that the department of health shows they report 2473 providers but there's only 1368 FTEs practicing in Vermont and based on our hospital budget information there's 1135 FTEs that are employed in our community hospitals for 83 and this doesn't include travelers or local tenants the community hospital physician revenues it increased from 36 percent in 2011 to now it's 50 percent of the revenues in 2019 this is a newer slide I hadn't showed this one before I'm showing you the FTE staff from our hospital budget information that there are 15,030 FTEs which includes 282 travelers or two percent of their staff we're hearing this is increasing more and more each year and then in comparison in 2015 the hospital staff was only 13,638 and the travelers was half it was 141 in 2015 but I also wanted to show you the pieces of this is a tree chart of staffing in our community hospitals all other FTEs would be like administration that are in others like facilities maintenance things like that that are not included in these other categories we'd like to hear from the hospitals for in migration from out of status and I've showed this slide in the last few years this one I'm showing from 2017 to 2019 so like for instance Southwestern Medical Center in 2017 was showing 32 percent of their patients were coming from out of state now it's 28 percent but on average but through both years it's 13 percent across our hospitals in Vermont community hospitals a lot of people wonder how come what's the shift between the resident analysis and the provider analysis how come it's so different some of it you will see in the resident side there's nothing here under hospital positions because this is being reported under physicians this category here but also on the provider side you can see this is less for physicians because it's now included under hospitals because they're hospital employed physicians the other thing difference is you will not see admin net cost of insurance on the provider side but you do see it on the resident side that can cause some of the change the provider side does not include rebates for drugs and supplies so this is a larger number there are some of the differences um because the statute told wanted us to have projections for the 2019 through 2020 and 2020 2021 this is what I came up with I've tried to be very cautious but I didn't have a lot of data here so I mainly had Medicaid and I was trying to do um growth based on 2019 and um cautiously giving growth for the 20 and the 21 years um this is going to be interesting to see what happens when I go to report for you next year for 20 on the provider side we at least have the hospital budget information so I could give you that for 20 and um I did my best on trying to give some kind of a growth but didn't go wild because of the pandemic so our next steps we are working more in collaboration with other teams in the Green Mountain Care Board so that we can give you better information and um more interactive information and that you can use the information easier so efforts are underway to extend and enhance this to better account for changes in the payer delivery system a lot of what the ACO is doing in the all payer model we are partnering with more subject matter experts who can identify our needs and determine a meaningful way to address these for you and then new methods to pilot this and to estimate and to give you a better product for even the next one in 2020 then the rest of this is appendix it's for your information I can go quickly through it is like this some people like to see the matrix of the expenditure analysis all the different cells what make it up and then that's a resident then also what is the commercial insurance what does that look like because I had mentioned to you about admin net cost of health insurance so you can see here the changes that make that up their change in surplus or admin the negatives and you could also see which insurers are showing more for hospitals or drugs and supplies whatever and then the provider analysis the same look and I would emphasize the color schemes because then you will know what is estimated and what is coming directly from providers or in this case pairs and this particular slide we're using this look this year because it's showing the health insurance coverage and it's not showing you the total population but just breaking it up with who's got the insurance coverage and this information is compiled from multiple sources as I'm noting down at the bottom here comes from the ASSR the household health insurance survey comes from vcures diva and then in the past we used to use Dartmouth institute for health policy and clinical practice now we're using vcures then I'm showing you the different sources for my methods and and notes and what might change and what we are going to be you trying to get better sources for some of these things that we're having to calculate because we don't have direct sources and I'd like to acknowledge all of my fellow team members in the green mount care board for helping me for giving me peer review suggestions and things like that I also reach out to the agency of human services for a lot of information I reach out to individual provider agencies I reach out to commercial pairs and they all help to inform this particular analysis so questions okay board members are there questions for lori yeah got a few first thank you very much it was very comprehensive as always this this deck is um going back to looking at you know I guess the two biggest drivers of the change year over year with the drugs and supplies and the hospitals and the drugs and supplies were up 135 million and do we have any color on you know understanding if those are specialty drugs or you know what's driving that huge change and it's it's been something that's been happening for the past several years not in the data that I have because I'm only I have not asked that specifically I'm only asking what's the particular categories that they're seeing the spending in um the CMS will say that that's a lot of the the drivers is your specialty drugs if you look at their um um literature so that would be true and the other thing marine is as I mentioned is the um they team and I are also looking at the supplies piece of that because that feels squishy we'll call it if you want to use that terminology because it just is weird and I want to dig deeper into that but that's part of that growth it's growing more than I'm comfortable with okay and another part and I'm going to look at both the um the drugs and then and then do the same for hospitals so in the 135 million increase that we had for drugs and then when we go down to the payer type reimbursements 23 of that was in commercial and then when we get into Medicare it was the bulk of it 79 or 69 and then um the drug piece was actually down slightly for Medicaid but the question is I wonder if when we look at the reimbursements if the reimbursements and the increases um are more are absorbed more evenly across the payers and let me contrast that with hospital spending the hospital increase so the hospital increase was uh 91 million and of that 91 million in the hospital increase commercial picked up 63 million of that change yet commercial lost uh number of people who are covered under commercial year over year so the you know the bulk of the the hospital increases all got hit with commercial and I'm thinking that may be because the other payers aren't really picking up much of an increase year over year and it's all hitting the commercial payer and don't know if you can talk to that at all right not in this particular analysis we can try for the future ones okay so it's just something as we look at you know disproportionately you know it's particularly for when we look at the hospital increase it's two thirds of it is going to commercial payers and relative to the fact that they're actually losing members slightly year over year uh to me it it looks like it could be because as we know the other payers aren't necessarily taking such large increases year over year um so I think what Tom would pick up on would be the cost shift right for right right there I'm listening yeah so um that's all I have but it very helpful information a lot to digest in this but it always um is good to look at um you know in total where all the spending is um and you know how that's playing out year over year so thank you very much thank you okay other board members yeah maybe I'll just pick up a little bit on Maureen's thread um I'm just wondering Lori first of all thank you I know how much work this is and so I really really appreciate all the work that you do and compiling all this data every year um and I'm wondering one of the things that I'm concerned about or just thinking about is we know that there's been a major shift from independent practices to hospital-owned practices and you know that's happened nationally but it's also happening in Vermont so I'm just wondering since the hospital revenue includes revenue for hospital-owned physicians before they would have been counted obviously in physician revenue and in the physician bucket but now they're being counted in the hospital bucket right am I am I understanding that correctly basically we're counting them that way because we have the data in our hospital budgets yeah on the other side for like the resident side that's how the payers are accounting for them because they're seeing it in physicians right I guess it's where the claims are going too but yeah you we're seeing that and like you said nationally it's almost 50 50 right and I guess what I'm just saying is that does that in some of the analysis that's being done does that basically overstate hospital revenue growth and understate physician revenue growth um because basically what would have been counted in physician revenue growth before is now an ownership change and now it's counted in the hospital so I'm just thinking about how we look at hospital growth and physician growth over time when there's this fundamental change in ownership of physicians but it's not a fundamental change in you know what we think of as physician services and what we think of as hospital services so I'm just wondering how we look over time is there any way to unpack you know hospital pure hospital growth from hospital growth that's inclusive of physician-owned practice is growth um basically that is a great question because we've been trying to get physician revenue from the independent physicians for many many years and is we have to probably try harder to get those sources I've used census data I've used uh department labor data but also keep in mind the physician revenue side will not have a facility fee that the hospital physician side will have there's there's some of the increase but you're absolutely right we've got to try and unpack what is where is the growth if it had remained the same yeah I guess I'm just trying to understand that you know if we really want to understand hospital services and how that's growing over time I don't want to have counted in that bucket a hospital-owned primary care practice because that to me is is not necessarily what I'm thinking about as hospital services do you know what I mean so anyway I guess it's a it's it's a problem of where the data sources are I get that I'm just trying to think of how we unpack that um I guess my my second question my last question is Lauria you you know you lead this effort and you're also one of the key members of our hospital budget team so I'm wondering are there particular learnings that you see having dug into this data year after year that we should take with us into the hospital budget process um one of the things one of the slides that I found really interesting and helpful was the the slide that had the percentage by hospital of um out of state you know resident care being delivered you know like southwest being really high and um in terms of out of state the proportion of their patients that are coming from out of state and I'm just wondering that would be helpful to have in the hospital budget process as we're thinking about where is revenue coming from and there's probably other slides in here or other things in here that you you notice with your hospital budget hat on that we might remind ourselves about you know when it comes to hospital budget time and I'm just wondering if you had any thoughts on that basically it's like your last thing that you said is remind ourselves about but my data this is 2019 and you're going to be 2022 budgets so things have changed slightly so that's where it would have been great if I could have if we had gotten all the data for 20 and be able to inform you for 22 but that's huge wishlist because we're still starting to collect that information um I can all we can say it's you're absolutely raised to just give it to take into consideration these particular things when you're looking at hospital budgets the inpatient from out of state or things like that yes but also we don't have who's going for these hospital budgets who did they lose to out of states great yeah thank you Laurie so appreciate it thank you okay other board members I just got one question and thanks again Laurie every year this is just an amazing task to uh to actually see these numbers kind of tie out you know independent of what database that you're looking at it's uh it's quite a feat um but I'm I kind of this is maybe more of a uh you know just you meet people on the street and they're always and we're often outraged about healthcare costs going up over time and uh and not necessarily their particular healthcare costs but just generic healthcare costs which is you know what your analysis um uh covers and um but if you know as I as you went through as I went through it and you went through it we're looking at like 13 percent of the resident spend is out of pocket um and the commercial increases are um on a trend you know from 2014 to 2019 and I think a 2.1 percent and uh year over year 3.7 percent and I'm just wondering if you were one of those outraged people where would you go in this data set to say see I told you so healthcare costs are outrageous and growing at these double digit or exorbitant rates because I don't see that in this analysis I would not be able to point them to just one thing because it's it's everything it all has to melt together and we're all paying for it either in our premiums or our taxes right I agree with that but I just don't see the system growing at at I think what is the popular understanding that it's growing at least high single digit rates and maybe even double digit rates I don't see that anywhere I think when we first started in the green mountain care board we were seeing it but then it started to shift because of what was happening at the government at the federal government level too so it's starting to probably not grow as fast where it's slower and that's why it's hard to look at the data I'm giving you is one year snapshot we should look at the trends or the trend lines for times and I think that we're all doing as much as we can to try and slow those curves you know no I I agree and I was looking at the 14 to 19 you know 2014 to 2019 trends and and I just I just can't get as outraged as as some people do about it I Kevin uses the the hospital chart going back to when the green mountain care board was actually put in play here and it's a pretty good record you know from then to now and I think your data kind of affirms that yeah because of the information which also includes their other operating revenue because we want to keep it the same as what we're asking from other providers so what is your total operating revenue not just npr you're right thank you and nice work thank you okay other board members hearing none I'm going to open it up to the public for public comment members of the public and I'm going to start with Rick Dooley hi thanks so much I always find the numbers just you know fascinating as you go through them I just wanted to to Tom's point I think the issues if you see stuff going up I don't I agree there's not these double digit increases but you know if you see increases of you know two three four percent year after year after year after year after year you know three times five you have to 15 percent and I don't think people are seeing wage increases of two three four percent year after year after year after year so you know I think it's that's where you're seeing the disconnect is is everyone sees it in terms of percentage of their income you know they look at their increase in health insurance premiums they look at their lack of increase in salary or take home pay they look at everything else being more expensive and I think that's where you're seeing the uh the outrage so I agree I don't think you can point to the number and say you know you can point and say geez you know three and a half percent that's not too bad four percent that's that's not too bad but if you haven't gotten a raise for three years that is bad that's up so I think that's in my mind that's sort of where you're seeing the outrage just a comment nothing to no question there thank you again thanks rick other members of the public uh it's walter kevin go ahead walter uh thanks kevin um to tom's point again I I think tom is right about the green mountain care board I just want to project what would happen if the green mountain care board had not been there these prices probably would have gone up into the double and at least double digits you know teams 20s every year I'm seeing this in states where they don't have a green mountain care board you know 25 30 percent is not unusual and to so kudos to tom for that and to rick's point it's not just that our wages don't go up which they do not it's that we're always told that private insurance and that this system is the most efficient in maintaining costs or saving money when all it does is raise costs and it's not only in premiums it's in deductibles and out of pocket because when you consider all of this most of some of us have to spend $10,000 even before we can the insurance kicks in so that's part of the outrage is that we first of all the insurance has shifted costs on to us the costs keep going up and we're always being told that it's more efficient so than a single payer type system and that's where the outrage is coming from and rick is right about wages you know I haven't had a 3.5 percent increase in wages in probably 15 years the wages just don't go up anymore so that's where that's coming from thank Kevin thank you walter other members of the public oh yes mark sanislaus actually um I just have a quick question about these numbers are you able to tell the difference between utilization and rate and what impact the aging population has on it lori did you hear that question yeah yes um no we we have nothing on utilization in these numbers so you know part of the drive-up of the numbers well we don't know how much of it is it's just the patient needs are driving the increased cost versus how much is a pure rate change right now that's the only point I wanted to make thank you we also don't know if it's proper utilization or not I mean that's part of the problem we don't have all the answers yeah I'm just responding to the question that when you look at the total cost that you need to break it down and that's an important point Kevin and we also don't know if I will hear what we heard earlier from a private ACL saying they went out of they basically went out of business because they felt their utilization of cost were good too so I mean there's a lot of variables here and and it's complicated I mean it really is and mark your line of question gives me a chance to actually say some positive things that have not been picked up in the local press but there is a national study that came out that showed that Vermont is doing an incredible job of not doing over hospital use in that it's across the Vermont hospital system but also both UVM and Dartmouth were in the top 15 academic medical centers tier of keeping the improper use down so it's a good story it's just nobody's talking about it well thank you for the sharing that Kevin we appreciate it okay well that's good to hear that both of you for being at the right side of the list yeah well I mean I mean it's good to hear that both of the the state's tertiary care facilities are falling in the same category too so that's another good story for the state I think yep okay other members of the public hearing none um Lori I'm sure we're going to have more questions as we ponder this over the next few days and we know how to get ahold of you and I want to thank David and Jess for their assists and everybody across all the teams and throughout state government that you work with to compile this report every year it's one of the reports that I really look forward to every year and that's that's probably not a good thing to publicly admit that but it really helps me to understand where we're headed I'm I'm actually a little bit down because we had made some progress as a percentage of our gross domestic product in 18 and that slipped away in 19 um but when you look at the rest of the country we're still doing pretty darn good and um thank you for compiling the report and um at this point I will ask if there is any old business to come before the board is there any new business to come before the board hearing none is there a motion to adjourn so moved second it's been moved by Maureen and seconded by Tom to adjourn all those in favor signify by saying aye aye those opposed signify by saying nay thank you everyone and enjoy the rest of the day we had hail earlier here at the start of the meeting but it's sunny out now hopefully my car didn't have any damage bye everyone bye