 I just have two announcements about open public comment periods that are going on right now. The first is from May 13th to July 24th, 2019, there is an open public comment period on the proposed 2020 QHP qualified health plan rate filings and then the second open public comment period on our website is on the FY 2020 ACO budget guidance that started last Wednesday June 5th and it closes June 17th and that is all I have to announce. Did you have anything? We're all set. Thank you. The next item are the minutes of Monday, June 3rd and Wednesday, June 5th, 2019. Is there a motion? Second. It's been moved to approve both sets of minutes without any additions, deletions, or corrections. Is there any discussion? Seeing none, all those in favor signify by saying aye. Aye. Any opposed? So now we're going to shift. We're going to invite John and Hannah to come down and we're going to give you the quarterly update. Welcome on this beautiful day. Yes. Thank you very much for having us for our quarterly report. It's been a lot of activity in between. It's interesting we're not going to inundate you or put you to sleep with bounds of data. Different kind of work has happened since we last came forward. My favorite kind of presentation. Hello, thank you. Take it away. Thank you, John. So I'm going to start the presentation with just a reminder and re-grounding on what our goal is for this project. We are providing an analysis and engagement and planning necessary to design and create the UVM Health Network inpatient psychiatric facility and or unit that will substantially improve access to inpatient mental health care as part of an integrated system of care in Vermont. The inpatient psychiatry facility planning is grounded in a few principles. Those are that we will design and create a UVM Health Network inpatient psychiatric facility on the central Vermont Medical Center campus that will substantially improve access to inpatient mental health care as part of an integrated system of care in Vermont. We'll anchor our planning in a data-driven evidence-based process to read that that's possible. And we're committed to providing a forum for interested stakeholders to give input to inform the planning process. And I think the board has heard us talk about the psychiatric inpatient planning stakeholders team. We meet quarterly and their next meeting is July 9th. We also want to create opportunities to share information publicly including community forums, legislative briefings, media relations, public reporting, et cetera. And we did meet with Commissioner Squirrel about a month ago just to bring her up to speed on all the data and the process to date. And she found, I think, found that helpful. We have a supporting structure that we're utilizing to do this planning process. All of this work, of course, reports to Dr. Brumstead and both myself and Dr. Perantini serve as chairs. Dr. Perantini sends his regrets that he's not here today. He normally would be here presenting the programming piece, but he had a full schedule of patients, so he was unable to attend today. We also have a steering committee that is a broad variety of constituents that meet quarterly. We actually met yesterday and gave them an update similar to what we'll be giving you today. And then we have a psychiatric inpatient capacity planning committee that meets more regularly about every other week. And again, they're really more in the weeds and supporting the work as we move forward. So previous hearings, we've talked about phase one where we identified the size and scope of the facility. We are now squarely focused on phase two, which is design and operational requirements. For phase two, we've refined the supporting structure to include a few other elements. The first one is a facility programming piece, which I'll spend most of our day-to-day discussing. We also have a facility location team that's meeting to discuss and articulate where a potential location would be on the CBMC campus. A schematic design group, a financial and operational impact group, and then finally a CON and outreach group. And I'll talk about those in a little bit more depth in a bit. The project timeline in May of this year, we have now completed the programming piece that work is done. We are moving into facility location identification. We hope to complete that by the end of this month to early July. Next in August, we are targeting to complete the schematic design for the facility. In September, we're looking to complete the business planning process and get internal approvals for the business plan. And we're driving to a December 2019 CON submission. I'm going to spend the rest of the time just really getting into more detail about space and facility programming. So our goal for this phase of the project is really to identify the space and facility requirements to support the care provided to people receiving adult inpatient psychiatric care and services at CBMC. In an earlier remount and care board hearing, we presented the analysis of needed bed capacity in Vermont and the IMD rules that will limit the number of additional psychiatric beds that can be built at CBMC. And I think you'll recall we arrived at the number 40 in total. The programming work that continued after our last presentation was focused on identifying the staffing and programming space needed to provide care for Tier 1, Tier 2, and 3, and then patients entering the facility. So we identified three work groups that focused on those three areas, Tier 1, Tier 2, and 3, and intake. Each work group met for three two-hour sessions, and it was facilitated by HALSA advisors, which is a planning consulting group that we use within the network. A total of 48 individuals gave their time and knowledge in this process. And I just want to pause and acknowledge all of those individuals. This is not a light lift. They were actively engaged. They attended all those meetings. And there was some really robust discussion and input, which I think was incredibly valuable to process. They began their work on March 19th, and they completed their work on March 10th. Excuse me, May 10th. Thank you, John. Their efforts were focused on reviewing operational processes, staffing, and the space needed to assess and treat patients in the facility. They gave their input freely and shared the perspectives on space, processes needed on an inpatient unit, including patient rooms, how food would be delivered, environmental services, therapeutic and green space, and staff work to support the care processes. The outcome were recommendations related to staffing and space tables that correspond to the functions identified in operating the total inpatient psychiatric service at Central Vermont Medical Center. In addition to the workgroup session, three site visits were conducted to inform the process. And how we arrived at those sites is, first, we took advantage of the site closest to us, the Vermont Psychiatric Care Hospital. And then we leveraged a consortium that we have involvement in that's a national consortium of academic centers that have community hospitals. And I reached out to COO colleagues and asked them of the group who had built or renovated an inpatient psychiatric unit in the last five years. From that we had 25 respondents. We interviewed all 25 of those organizations, leaders and teams, and came down to two areas, sites that we visited. One was Lancaster Behavioral Health Hospital in Lancaster, Pennsylvania. It opened in June of 2018. It's a large facility, 218 beds with a variety of subspecialty units. And that gave the teams that visited a real variety of space and support space to enable care of the population that we're treating. And then we also visited a Regents Hospital in St. Paul, Minnesota, which opened in December of 2012. It has five 20-bed units, so a total of 100 beds, and they provide care to the similar patient types that we're looking to support in our organization as well, Tier 1, Tier 2, and Tier 3. Insights from those site visit participants were brought back to the work groups and lessons learned were shared. Again, all of the work groups had really good exchanges, lots of shared learning across. Also took the feedback and suggestions from each of those meetings and continuously modified the documents to describe each of the three program areas. At the last session, we actually had the architects that are going to be going with us on this journey joined the session so that they could hear the insights from the teams. And that's just, we hope, will expedite the architectural and schematic design in the next phase. At the end of all of the work groups, each work group approved a final document. So this is just a list of all the individuals that participated. As you can see, it's very multidisciplinary. Particularly want to acknowledge the peer advocates that were participants as well as patient and family advisors that are part of our Patient and Family Center Care Program. But you can see there were a variety of individuals that participated, 48 in number, and all of the work groups were facilitated by HALSA advisor. Additionally, I want to mention that for Tier 1, we solicited input from the Vermont Psychiatric Care Hospital. We again thank them for their participation. They shared their lessons learned of what they would do differently if they had the opportunity in their own organization. And that also was a very rich discussion. And what really what we found happened in these work groups is there was a nice exchange of professional knowledge, personal experience, and then the input from these site visits really made for, I think, a very rich and in-depth programming plan. The space and staffing tables are a result of all this work. And they're used to inform the next-age planning, which is the schematic design, which is just kicking off this week, and that's being led by our architects. So as mentioned, we've revised the project planning support structure for this phase of the project. These were outlined in the schematic that we're back on slide 5. But we broke it down into four teams that will continue the work now in this phase of the project. One team will focus on identification of the facility location. And we're taking results of all the programming space tables and beginning to work to size the psychiatric capacity and identify also the location on the CBMC campus. And again, we want to align the location with Central Montmethical Center's long-term master's facilities planning process. Another team which is launching this week is working specifically on schematic design. So they're starting now and will focus on design layout for Tier 1 patients, Tier 2 and 3, who have similar treatment characteristics, and then the intake through the emergency department. We are asking for the individuals that were part of the programming to stay with us on this phase of our planning journey. So peer advocates and other members are being asked if they would participate in this as well. Again, their insights were invaluable to us in the programming phase and we believe that they'll have the same effect in the schematic design. So we want to build on all the knowledge that they've gained by going through this very intuitive process. A third group is focused on financial and operational impacts. That group will identify operating and capital costs for the inpatient psychiatric facility and they will develop plans for capital funding and assumptions driving reimbursement to support inpatient operational planning in the future. And then the last team will focus on outreach, engagement, and then drafting the certificate of need, which again we're driving towards a December 2019 submission. And as I mentioned previously, the next inpatient psychiatric planning stakeholders team is July 9th and we'll be sharing with them more in depth the results of the planning. And we're asking if some of the participants would share their experience of being part of that process with the whole constituency. So with that, I'll pause. And we're happy to answer any questions, obviously. Thank you. Mr. Bort, huh? Well, first I want to thank you all for the work and the timeline. It's all started back in March of 2018 and here we are, some less than a year and a half down the road. And you're hiring architects and seeing a kind of an ending to the planning and design process in December of this month. So that's a lot of effort in a short period of time. A couple of questions. So in your 25 interviews with kind of recently candidates for recently built facilities and the two that you visited, did you get, especially with the two that you visited, did you get a sense that they were state of the art facilities and did you get any sense of what the construction cost for that was? I think that they, I personally did not go on the site visits but from what I understand from those who did. That they saw a lot of what they labeled as best practices, things that they would want to replicate in our facility. They also, I think the individuals that they visited were very forthright in sharing things that they would change even though one of the facilities was built in 2018. So they were very willing to share, you know, we thought this would work. This is not ideal. This is why. So they were very open to sharing sort of their lessons learned. They did allow us to take some photographs of the building facility itself. I don't know that they disclose the actual costs of the facility and as we go down the road we can certainly get back to them and have that detail of conversation with them. But because it was a multidisciplinary group that went, I think they were focused more on operations and the design and how the flow worked. Programming that they had and they were even picking up on color schemes and artwork and those sorts of things and learning from the individuals that they visited with. What's working well and what would they do differently if they had the opportunity? Obviously my role in the network includes overall understanding our capital allocation debt and so in that context we've started to really just in very rough terms understand what this type of commitment is going to mean. Again before we're really looking at sources or anything like that. And it's obviously goes hand in glove with site selection on the campus and how it dovetails with set for months facility needs. Just total back of the napkin at this point. And obviously this will have laser focus on this over the next four or five months. We're looking at three to five times the commitment that we made back in March of 17 to really get this project over the finish line. But again that's obviously really rough but gives you sort of the bookends of what we're thinking. So it seems by the time line that by the time September comes around we should have a tighter set of bookends on both the operational cost per bed and the construction cost per bed. They'll be tighter bookends definitely because we will have done the site selection there. They will have gotten into schematic design. But until we really get the business planning down and get probably within three or four weeks of actual CON submission the numbers are going to move. And that just not dramatically obviously will get less and less as we get closer and closer to submitting the CON. But that's the cost obviously goes hand in glove with the design elements as they come on. So probably in our next quarterly meeting we can be a little bit more specific. But it still will be a bookend kind of financial estimate. What's the architects firm that you selected? E4H. E4H, formerly more Switzer. And we have literally decades of experience in Vermont and with our organizations with both HULSA and E4H which I think has been an accelerant to our process. They know us really well. We know and trust their work. And they have both HULSA and E4H have shown willingness and capacity. If there's one little thing that they need some special expertise to go out and find that expertise which I found very useful over time working with them. They also both have both planning and design experience with inpatient psychiatric facilities which was also important. Other questions from the board? In all of your research is there something that you've learned that's unique to Vermont that would not be transferable from the Lancaster to the Minnesota site? Is there anything that makes our delivery system or our existing infrastructure unique? I didn't hear anything from the groups. So the clinicians coming and I hope everybody on the board and everybody in the room feels good about this. From the clinicians particularly that went to the Lancaster site, their biggest takeaway was the vast majority, 90 plus percent of the people that were inpatients in that facility wouldn't be inpatients in Vermont. They'd be taken care of in the community or with other services which they found reinforcing and a good takeaway. But there were also design elements particularly for tier three that they took from that facility. But I wasn't on the site visits either but in hearing people coming back that sort of was a oh that's nice. Thank you. Were the Lancaster and the St. Paul sites co-located with the hospital? One was a standalone facility and the other one was connected to another larger possible site. But one was literally in the middle of land that had nothing around it. It's quite a large campus though. So as part of that site visit to the one that was co-located, do you think there's also been an opportunity to speak with people inside the hospital side to see how things were matched? Yes. Yes. I think both organizations were wonderful hosts. They met with the leadership team first. And then they met with the clinicians in the psych units and they had an opportunity to speak with administration from the hospital side as well as the leaders of the psychiatric facility. They were very forthcoming. It's great. It's great to see all of you because no matter how hard you try there's always going to be a little incidents that occur along the way. You know recently we had emergency CLN from a relatively new psych unit in Rutland. We hate to see any similar mistakes repeated. So it's good to see that the teams are being crossed and the guys are being done. So thank you. Absolutely. And I think that's really the power of the site visits. There's nothing that replaced actual seeing an organization and seeing how it functions. There's a big difference between design and actual living in the space. I think they were also very forthcoming with what their lessons learned would be. And as I mentioned before even for the facility that just opened in 2018 they had lessons learned. They also shared with us that as we move through our process they're very willing to work with us collaboratively. And continue to stay in a partnership with them just to share what we're learning and what we're experiencing. So very collegial approach which was very helpful I think for the team. And again I want to thank the individuals that went including a peer advocate. Which I think was also very powerful for that individual as well as the whole team to see both of these organizations. And think about those organizations in contrast to what we're trying to achieve within this space that we're designing. So nice experience for them. At this point we'll open it up to the public. Any comments? Ken. Thank you. You look way too relaxed. Pardon? You look way too relaxed. I'm jealous. Well I've been trying to think of negative things to say as an old advocate. I think last time I did say that this has been a strong team as things have moved forward. And I'm certainly not ready to say that Anna Noonan and Dr. John Brunstead are part of the dream team. But they are showing some real potential. So I think as a member of one of the advisory committees I have to say that it's been a very open process and good dialogue. At the same time it's almost too relaxed and feels good when in fact over the next couple of years including tonight there'll be people who can't get access to emergency, to psychiatric beds, sitting in hospitals, in emergency rooms. It's very tranquil here. But if you're one of the family members with a patient in an emergency room, this is a bizarre and horrible crisis. And so I can't help but mention that it's actually a disgrace. And the fact that the governor and the legislature really did nothing in my opinion to significantly address the issue is really unfortunate. But that's just an editorial. However there's a couple of things I did want to ask about and ask the leaders of the project and the Green Mountain Care Board. There's no great secret that the board made a very interesting in some ways courageous decision to put aside what will be over $20 million towards this initiative. And I do wonder since a year has gone by has the board received or is there a public way of accessing the question of what's the first year budget report? You know in state government as lax as it can be at times there's usually a public disclosure of where money is spent and how. It's in no way a negative criticism although it could be. It's certainly a negative criticism that there isn't, you know, on front of us right now just a one year report. I assume the board has seen it so they know where the money that's been allocated has gone. So that's one question. And second question really is a different question though I'll just say it very quickly. For many, many decades actually I tried to stimulate more interest in the private hospital sector to do a project like this going back. I remember the first time I talked about it was with a young member of the House from Burlington. He was a doctor, Howard Dean. And we talked about shouldn't hospitals be stepping up to the plate. And the reason always given or often given very often informally was in essence running a psychiatric unit in a hospital is a money loser. And there was not much incentive frankly on the financial realm just to be grossly honest about it. So the question I also have, the second question I have is on a scale of 1 to 10, given what UVM Medical Network knows now, what's the probability of actually being able to financially pull this off when seemingly over decades no hospital has been able or willing? And I think it's very much because of the, there are other reasons but the financial reasons are major. So those are two different questions. One is where's the budget and where's the expenditures? I'll start tackling the first one initially and then pass it off to John and Hannah. Basically all the reports that we receive from UVM are posted to our website. And Susan is just assured me that she will forward you that information so that you have it correctly. So we're always transparent. Anything that we receive gets posted. So John do you want to handle the second part? Yeah, just to reiterate it is part of what we agreed to right up front in these quarterly written reports to the Green Mountain Care Board that would include the spend to date. There are two inpatient units at the University of Vermont Medical Center. Forget the census of each. It's about 20 beds in each of those units. And the Medical Center, if you just look at a P&L, a profit and loss with usual cost allocations, there's a loss of about two million dollars per year per unit. So four million total. There are models, particularly those that have evolved over the past several years where there's reimbursement, particularly for level one patients that do cover the costs of caring for these complex patients and we have not begun those conversations with the agency of human services or the state. But now's the time to start doing that. So over the summer we will begin to engage with the leadership of Department of Mental Health and AHS on that because obviously that's a, as you point out, kind of critical element to put in the business plan. That's a critical element to be part of the CON because it's not going to support any of us or this very vulnerable patient population if we're not covering the costs of the services because you know what happens when you have services where the costs aren't being covered. They get short-shifted and we're not going to allow that to happen. So we're going to start those conversations. We haven't had them yet, necessary ingredient in the business plan in the CON, so it will be very transparent when they get to that point. Other public comments? Questions? That's it? Thank you very much for that. I think that might be a record. One question. Transition over and invite Agatha and Michelle to come down. As we talk about the 2020 non-financial reporting, are you ready? Take it away. Thank you. Good afternoon. For the record my name is Agatha Kessler. I'm at Michelle's Degree. And we are here today to take you through the FY 2020 hospital budgets non-financial reporting. We have, I think, about 45 minutes, maybe a little extra because the previous presenter ended early, which might be good because this is a very dense report. Just to kind of go over what we'd like to talk about today, this is the first, we're going to talk about why we're here today and not until I first. We're going to go through the quality improvement initiatives and Michelle's going to walk us through that. Then community health needs assessment of the patient's access at many times, and we'll finalize it with staff recommendations. The staff recommendations are sprinkled throughout, but we do end with the summary of all the staff recommendations. So why are we here today instead of in July? This is the first year that the Green Mountain Care Board has come at hospital budgets and sort of a bifurcated submission process. So just to kind of level set the language from the budget guidance is up on the board and the goal of asking for non-financial information in advance of the financial information is to give the hospitals and the board and staff enough time to really pay attention to the individual components of the financial components and the non-financial components of budget review. This is a, oh, so we started with vetting the sort of CEOs and CFOs, the healthcare advocate's office was a part of this and also the Department of Health. The hospital is submitted on April 30th and we did the analysis that you're about to see in collaboration with the Green Mountain Care Board policy team and also the Department of Health. I will say that the individual submissions themselves from the hospitals are very important to review and read, so although this is a summary, the words of the hospitals are really important to kind of hear their story and their individual risks, opportunities, challenges, and strategies. All the information is posted on the Green Mountain Care Board website and just so the board members know, we are planning to print these and put them in your binder budget so that it will be refreshed in July when you're looking at the financial pieces. The slide I really want to put up front, it's a consideration section which is basically identifying any shortcomings or room for improvement in the data and the analysis itself. So the data is submitted to us by the hospitals according to their own methodology. The presentation today is labeled preliminary and that is because this information wasn't submitted, you've heard of talk about adaptive software, it wasn't submitted through adaptive, it was submitted email to us and we wanted to give the hospitals an opportunity to look at it as a system and make any changes or corrections to their needs. So it's marked preliminary for today. A system-wide analysis of this sort is very challenging without standard definition. So it's all explained as we get to each section. But for example, third and next available appointment seems very standard. It's defined by a federal organization or a national organization but it's more complicated than that. The shortcomings of the data or the analysis are described in each section, each of the three sections and we are planning to solicit feedback for the next time that we do this. So please, as you interpret the data, please consider it in the context of the considerations listed in each section. Any questions so far? All right. So I'm going to walk through the quality improvement initiative. So as you'll recall, we also included a set of all-hair model agreement measures in last year's budget guidance. The year prior we had used a couple of different metrics for hospital comparison. So again, we're looking at the same set that we looked at last year and you'll see my recommendation but I would obviously propose we continue to do this through the duration of the agreement. So a couple of things to just note here. In terms of methodology, I wanted to just call out. So the latest blueprint community health profiles include data about all of the people living in each blueprint health service area who are in Vermont's all-pair claims database v-cures. So previous profiles included a subset of people who received their care at blueprint patient-centered medical homes. So the change that they made really aims to make the profiles more inclusive, offering the most complete possible picture of health care and people in all people of the given community. However, this means that we can't compare this year's results to last year's results in terms of the information that we're looking at here. So you won't see a comparison to what was included in the fiscal year. Oh, hospitals, 2019 budgets in this document for any blueprint measures and that's something that moving forward we cannot do. The methodology has changed. Another thing I wanted to point out aside from some of the things on the board here that some of these data I know we often get told that they're old or they're outdated. But I wanted to remind folks that when I pulled this data and put it together for the purposes of this non-financial report, it was in February. And so as we move forward, there is a very real possibility that a lot of these will update by the time you have hospital budget hearings in August. I will leave it to the board to decide if you'd like to receive updated information prior to the budget hearings. I'd be happy to provide that to you or if you would like the hospitals to utilize what they've already submitted for this non-financial reporting piece at the hearings should you have questions on any of the information given to you. Just something I wanted to caveat that there's a very good chance these things will change. Additionally, I want to point out that targets that will be shown in the next couple of slides are statewide targets that we are responsible for meeting by 2022. So while we think it's important to look at each hospital service area or hospital specifically, just remember that really it's a statewide look that we're responsible for in term for meeting the terms of the agreement. Okay, so I'm going to give you two looks at this data. So here we're looking at results as applicable that are compared to the all-pair model targets. This looks really blurry but I don't have my glasses on so maybe it's not. So this is a subset of the 20 measures. So I just also know a lot of all-pair model measures have benchmarks that are or targets that are national percentiles and those are sort of moving rates so those are not included here. These are only measures that have sort of that set number that we can really compare to. So here indicators shaded in orange are showing performance below the target and indicators shaded in green are meeting or exceeding the all-pair model target. And this look does include two measures in the blueprint profiles. Again, we're not comparing to last year so we're just looking at the comparison to the target here so those 30-day follow-up measures were included. Variations in some of the other measures that we could compare to targets I've opted to not include here, I think like suicide rates because they fluctuate so much year to year and because one person can really create a pretty large difference in the data I've just opted to not include those ones in this analysis. So we can see here that with the 2017 calendar year which is what we're looking at we're meeting or exceeding in four of the targets again on the statewide level so those four are the 30-day follow-up for mental health, COPD prevalence, hypertension prevalence and diabetes prevalence and then we're missing out on three of them. However, again remember that these are targets for 2022 so any progress is really key here. This one is very colorful. So again, two looks. So here might get a little confusing because we're not looking at the same subset of measures as the previous slide but it's pretty close. So what I wanted to do here is look at where applicable and appropriate comparison to last year's performance on the same indicators. So again this would have been the comparison that was included in the hospital's fiscal year 19 budget guidance document. So again this is not any updated information from them. I simply pulled what we gave the hospitals to respond to last year and compared it to what we gave the hospitals to respond to this year. So here any areas highlighted in blue are showing improvement. Yellow are showing no change from the previous year and purple are showing a decline. And I will note that on some of the declines because it looks very purple it's usually maybe one percentage point two at most. It's not a huge discrepancy, or I'm sorry, a huge decline. Another thing I wanted to point out here, well also here I'll call out, so Table 2B which is the one in the middle there and I will thank Dr. Holmes for talking with me about this earlier. So here we're talking about improvement, right? So deaths to drug overdose, obviously a lower number is an improvement not a higher number. So that one's a little, you could consider it inverse but it's not. I did want to point out here that I took a different approach in this year's guidance document than last year for the last table listed. That's why that bottom row is not shaded in any color. And in effort to provide more context to the emergency department visit information I opted to include another data point which is the percentage of those ED visits in 2017 specifically that resulted in an inpatient admission to sort of help the hospitals in responding to this indicator in their non-financial reporting responses. I had found it to be a really interesting data point. We're seeing an average of 17% of ED visits resulting in an inpatient admission. Again those are visits with a primary diagnosis within the mental disorders category which is what we use, the grouping that we use to identify these. It's approximately 2200, a little over 2200 people. Some key themes that I noticed throughout the responses were definitely utilization of existing state programs for community benefit. So those are things like the diabetes prevention workshops the tobacco cessation groups that are held many hospitals have those offered through their community wellness initiatives and a lot of themes related to emergency department and substance use or mental health but also one that I found really interesting was for those patients who present to the ED with no primary care provider listed hospitals working to set them up with someone within their area and that came up in more than one hospital response which I found really exciting and also just general processes in place for identifying patients' meeting services. So a lot of times we see that common theme with well child visits, things like that that practices are already running to make sure that their patients are being seen as needed. So a lot again to mental health and substance use we're seeing a lot of talk of staffing for patients presenting in the ED who need these services talking about medication assisted treatment initiation in the emergency department that came up several times. We're also talking about transitioning ED space into safe and private areas for patients who are awaiting admission elsewhere. So recommendations moving forward I think moving into year three of the quality measurement reporting so for their fiscal year 2021 budgets we could consider trending in some areas where it's appropriate and continue to look at those over time as we move on through the agreement. Our first federal report is due at the end towards the end of this year in September so I kind of left this note here it's kind of vague just in case but at a time we may consider a deeper dive into certain measures for the guidance moving forward I think until we really have a good look at all of that data and understanding of what we might be seeing or variations across these HSA then we might have more pointed questions we may ask the hospitals in future years as we start doing more of those federal reporting and those deeper dives. And then of course consistency within our regulatory process is always a top priority so we've also asked the ACO to respond to the all-pair model quality measures in their budget guidance as well as a response to any of their payer contracts so all the quality measures that are in their payer contracts in their guidance as well so you'll hear from me again on some of the same things at ACO budget hearing time because like I said we've also asked them to sort of put their take on some of this. Do you all have any questions for me before we move on or do you want to hold everything until the end? Thank you both this is great it's really nice to have a statewide kind of look at what's going on with the quality measurement understanding how many different players participated in reaching these I was actually pardoned but that there was any blue in the deaths related to drug overdose like that there's any and all to me is awesome I hope that that means we're making some progress in that area so that was the comment that just struck me I was expecting to see a lot of purple in that line and there is still a lot of purple but at least there seems to be some stabilizing improvement in some areas Absolutely Anyone else? Can we help needs assessment? Can we help needs assessment? Before we go through the results I just wanted to spend a couple minutes reviewing what is a community health needs assessment how we use it, how it's used in the state so first of all and as we know it is a requirement of the Affordable Care Act and it amended the IRS code it added sections to the IRS code that requires non-profit hospitals to conduct a community health needs assessment and adopt an implementation plan once every, at least once every three years the purpose of this sort of initiative is for communities, the hospital to identify health care and health related needs in the community so it's not just health care it's not just what kind of medical services they need, it's also food related or housing related, it's any sort of need that could affect on that whole condition Once that's done once the needs are identified then the community hospital can assess unmet needs and develop strategies to address them and it helps organizations coordinate efforts so there aren't multiple efforts moving in the same direction The requirements as set forth in the IRS code are that the assessment needs to define the community that's served that's usually a geographic community and at least in Vermont sometimes that community served goes into another state so there's communities in New York or New Hampshire, Massachusetts that are part of Vermont community health needs assessments The assessment needs to describe the process and methods used to conduct the assessment they need to list what community input was received they need to request community input and list what community input was received they need to prioritize the needs the needs that come in and describe the resources that would be needed to address the needs so these are the requirements of the assessments however there's no standard methodology that's been set forth by the IRS so the hospitals have adopted their own methodologies to comply with this requirement In Vermont, the way that it's used the Department of Health kind of at the beginning of the end they create a lot of the qualitative data that is used to create these reports and then they use the community health needs assessments and their own initiatives or their own priority setting For the Vermont Care Board we use it in COM review, hospital budget review we're trying to integrate it to some other initiatives like the ATRAF the health resource allocation plan and then the hospitals themselves use their own community health needs assessment I will say that there's some of the Department of Health here today, Kelly thank you Kelly for coming here nice to meet you, we've never met before so thank you for being here and Kelly is here observing and taking notes so a lot of you know standard methodology there is a common methodology and I'll just go through this quickly but it's important to understand how these reports are created because we use them and it's important to know what the methodology is personally there's almost always an advisory committee or a steering committee and on that committee it's usually a very broad group of individuals the reason the steering committee is important is because several times along the way there's judgment calls there's judgment calls about what the survey should look like who should be surveyed how should we interpret this data we didn't really get the results we were looking for how can we reuse this or not use it at all so generally it's members of the hospital staff leadership of the staff leadership of the hospital the department of health is usually involved community organizations like United Way the housing authority building right features law enforcement is often times involved because they are significantly involved with the community and sometimes the means have a law enforcement effect so in addition to the advisory committee the assessment usually has a qualitative research component which I mentioned the department of health produces several reports that are used to identify the indicators in the community so the breakfast in addition to listing a couple the breakfast the behavior or stack or surveillance is done the youth risk behavior survey census surveys any kind of secondary data that can be used to understand the community better then the third component is the qualitative research which is the community input is talking to community members one on one sending out surveys looking at focus groups some of the limitations of this kind of data collection one of the hospitals put it in my life is that they were very upfront about saying this is more of an anecdotal approach to understand the communities and a scientific approach but nevertheless it's an important perspective it's the community's perspective about what their needs are it's just a simple overview of what a common methodology is the hospitals are required to produce a community assessment once every three years and this is the schedule so this year Central Vermont Medical Center and Springfield updated their community assessment and then there's a big batch that's expected to be updated in 2020 mom so we're actually working with relatively recent data from most of the hospitals right now so what did we do with this data? We asked hospitals to prioritize their community numerically with one representing the highest priority we did not limit the number of responses so some submitted four needs some submitted up to 14 the categories were based on previous community health needs assessments so we gave them sort of a pre-populated list and gave them an opportunity to add others if they needed to and then we tried to assess the financial resources that were allocated to community benefits this is a question that's come up a lot from the Green Mountain Care Board from other state agencies that are very curious about how hospitals are investing in the community how much are they investing in their community we did this by looking at the implementation plans to support the community assessments and also at schedule H of the IRS 994 schedule that non-profit hospitals use to identify community benefits some of the considerations when you look at the results consider these things it became clear that even the word need had a different meaning could have a different meaning in different context so for example and I like to use one example because it is very relevant is that substance use disorder it's a need in the community and it's a critical priority in a community and a hospital could list it as a need in their community health needs assessment because it's a critical priority but they could choose not to list it because if it is such a critical priority and they're devoting enough resources they may consider it a met need not an unmet need so it was very interesting the hospitals could interpret the word need differently and you'll see that 13 out of 14 hospitals reported that substance use disorder was a need but one did not and we know for a fact that there is an issue in that community that the hospital feels as though they're meeting the need something else that can skew the results since again we did not we did not limit the number of responses so one hospital reported four but another reported 18 that can skew the results and we're trying to weight them the category definitions themselves are sometimes overlapping so for example physical activity and obesity that's one of the categories well that can overlap with another category which is acts of to nutritious foods substance abuse can overlap with mental health mental health can overlap with domestic and sexual assault so it's very hard to kind of put things in a cookie cutter but no less it's important when you're prioritizing your needs and doing your analysis and then one other thing that kind of can skew the results is that we did a hospital could use number one once so they could say substance or mental health is number one and substance abuse is number two and physical activity is number three or they could say all three of those are my number one priority so we didn't limit how the hospitals ranked them so that's a long way of getting to this slide which is the results so it's ranked from the least number of results down to the most number of results and the bottom access is the number of hospitals so there's 14 hospitals in Vermont and because of mental health all 14 hospitals reported that mental health was a priority in their community followed by substance abuse disorder but I would probably call substance abuse 14 out of 14 as well because there was one hospital that identified it as a critical need and it felt as though they were meeting the need Michelle I was going to ask if you wanted to call out any of the measures that are related to the all pair model sure thing so if we go from the sort of the top down to the most need we fit almost every single all pair model measure into one of these groupings so starting with suicide we have a suicide deaths per 100,000 rate going down to tobacco and smoking we have a tobacco use assessment and cessation intervention measure going down to chronic conditions we have statewide prevalence of three chronic conditions, COPD, diabetes and hypertension there's also a Medicare specific chronic conditions target as part of the agreement we go down to access to care preventative services and primary care we have a Medicaid with well care visits measure the percent of adults reporting they have a primary care provider asthma medication management a Medicare the CAHPS so the survey composite question on timely care appointments and information and then if I sort of lump the last to substance use disorder and mental health we have deaths related to drug overdose we have initiation and engagement of alcohol and other drugs we have discharge after the emergency department for a follow up for mental health and alcohol or other drugs we have substance abuse and mental health visits we have the Vermont prescription monitoring system opioid scripts we have screening for clinical depression and a follow up and we also have the number of the Vermont population receiving medication assisted treatment so that's literally all but one all pair model measure and I would argue that you could fit the last one into the primary care access one which is Medicaid enrollees who are aligned with the ACO however I didn't think it fit perfectly so I left it out but so that's 19 of the 20 that fit within the categories that the hospitals identified as their highest needs any questions so far alright this next chart shows that it's titled community need and underlying need and the reason that we included these is because part of what makes assessment and gap analysis so difficult is not only understanding the needs the substance abuse mental health to back up but understanding the underlying needs especially in rural communities like we have here in Vermont so for those of you who can't see what's up here it says this is in these three samples from Mt. Staten's community assessment this chart says most significant barriers to accessing services and this is the perspective of key stakeholders number one is lack of transportation number two is inability to pay out of pocket expenses difficulty navigating the health care system all the way down to child care basic needs aren't met so this is going even deeper than I can't see my primary care because I can't see my primary care provider because of these underlying needs and then the chart on the right goes even a little bit deeper and it's talking about underserved populations so these are categories of people age, race, gender so it's a very interesting analysis it's not enough to just say these are medical or medical related needs these are some of the barriers to accessing services so the reason I put this up here is that we did a great job and there was lots of great samples in all the assessments but this type of analysis would be very useful in assessing patient access in terms of looking beyond patient wait times which we'll see in a little bit and workforce issues which we see over and over and over again this chart's just kind of another way of looking at the top needs so this is a list of any need that was assigned a numerical value that a hospital said this is our number one or one of our number one priorities it is sort of listed from the mental health which had the most number one mental health which had the most number one down to early childhood family supports that had the least number of number ones. Alright this next chart finally we attempted to assess financial resources that have been dedicated to community benefits the first place we looked was implementation plan that supports the community health needs assessment and slow or alert they're not all done the same way so some include a financial budget that supports the community health needs, some do not and some projects span multiple community health needs so one example that pulled out was Rise Vermont is a program that improves primary prevention physical activity, social supports this would hit several of the categories but it's one one line at a time check so it's really hard to say how each one of those topics from that large chart is being financially invested into we also look at the schedule age of the 1990 and there's kind of a blow up of what we asked for specifically we asked for this other part other benefits E through K so again hospitals are using this all different ways they might include medical medical projects only they might include grants only they might include unremembered charity only hospitals are not using this all the same way some of the ways that it is being used is some hospitals are including investments in their medical services to treatment programs expansion of mental health services in the emergency room investments in Rise Vermont smoking cessation getting out free EpiPens so some hospitals are using this way using schedule age this way some are not so as we found it very challenging to put a dollar value on community needs really wanted to just take a step back and ask the question instead of asking how much how many dollars are being invested into the community perhaps a more appropriate environment would question to ask is how much investment is enough or how does the hospital know that they're meeting the needs or how does the hospital know that they're not meeting the needs of the community it's more of an interpretive self analysis that the hospital can do and sometimes more is not always better so if the hospital has a choice of investing in an existing program in the community that might address a need versus starting their own program starting their own program will probably take more money as effective so it's a very subjective analysis and one that we've had conversations with the Department of Health on so this leads to kind of the recommendation section for community helping assessment first our analysis which is that mental health and substance abuse disorder counseling continue to be the most widespread community need throughout the state and all the hospitals Michelle do you want to maybe go over this next bullet point because I think that came from you reducing deaths due to suicide drug overdose or tying together the falling measures and the community helping to do that yeah so reducing deaths due to suicide and drug overdose obviously is an all fair model agreement priority area so hospitals working to address the gap in care in many ways and so some of the some of the points that I have talked through are listed there including like I said before that MAT in the emergency department came up several times and I found that really fascinating you know we talk about MAT access a lot and we talk about it through Health and Health so we ask the ACO how many MAT providers they have in their network that's something that we're really trying to keep track of and better understand and that those patients are being served appropriately thanks Michelle in terms of resource allocations we're trying to ask that question how much are the hospitals investing in their community as we move towards population health addressing the underlying causes of medical disorders and continuing to integrate with the community with the community the financial assessment of the community benefits becomes even more difficult to evaluate so these costs are now being faked into the hospital budget so for example if you put a psychiatrist in the ER that's addressing a community need but it's not going to show up in schedule H and it's not going to show up in an implementation plan so it's very difficult as the hospital integrates with the community to extrapolate the finances another example is the ACO fees that are with Health those are meant to go towards the community community investment that's not going to show up in an implementation plan or in a schedule H so recommendations that we would have for July for when the budget comes in is some questions that you might want to ask or have the staff ask are how does the hospital use their own community health assessment how do they share their priorities internally how do they communicate that to the different departments and how does the hospital assess whether its level of community investment is adequate what we would monitor as budgets come in are any risks or opportunities that the hospital identifies that are associated to the new community any provider transfers or acquisitions that are related to community needs and any certificate of needs that come in or that were awarded to that are related to the community any questions about that just one back to the comment I think the potential questions you have for the hospitals I think that's going to be a good add whether it's during the budget process for next year we'll put those in both for here when we talk about the wait times and maybe it's something if we were going to ask those at budget time that we send it out beforehand to them because part of this process of separating these things from the budget presentation was to try to streamline things so figuring out how we could do that but I really appreciate the questions that you guys are putting up there and asking just a quick slide I'm looking forward to that we'll look at all the considerations we'll get feedback from the hospitals feedback from the Department of Health and we'll try to integrate the results of the community health assessment to other Green Mountain February initiatives like HRAP, CUN, and the all payer model next is patient access wait time and this is the last section so first what I want to say is that we're looking specifically at patient wait times which is a window into patient access but there are lots of ways to look at patient access wait times is just one of the ways that we've been collecting data so I want to stay out there in front because there's a lot of variation in the data that you're about to see so what did we do as staff or methodology we asked the hospitals to provide their wait times for all employer provider practices this is the first 2019 this is a recommendation from the CFO workgroup that we had just pick a point of time and stick with it because these wait times change on a daily, weekly, monthly basis so we asked if there's an available appointment as defined by the Institute for Healthcare Improvement I did take a look at what IHI goals are and they're a goal for you'll hear me say this later but we're looking for benchmarks the goal for primary care is zero days to the third next available appointment and two days for the third next available appointment for specialty care UVM and central Vermont use an alternate metric which is percentage of new patients seen within 10 days of the initial call so in there some of the difficulty in doing a system-wide analysis is that of 14 hospitals two are doing them differently some of the considerations and this is a long list is that the service types are not categorized so it's basically an alphabetical list of services that could be offered out of a hospital they're not categorized, they're not tiers so there's clearly a difference between primary care and neurology and you would expect that wait times might be different for those two but we're looking at everything kind of the same in the alphabetical list so in the future we might want to look at tiering the service categories hospitals added five additional categories so we did as we went back we looked at what was submitted last year asked for that same information this year hospitals added five more categories which is great but what that means is that it's possible that there are hospitals out there that provide one of those five services but since it wasn't on the list they didn't respond to it it might be we might be under-representing the services that are offered we recommend that hospitals be assessed in the context of their type whether they're PPS or critical access hospital and PPS hospitals are indicated by an asterisk you'll see them with an asterisk we at first I created a system average by service type and then decided I didn't like that because there's too many flaws in the data I shouldn't say flaws in the data inconsistencies in the data several categories have limited participation so only one hospital reported on dermatology can't really create an average with one hospital or even two hospitals and then if you have two hospitals but one's a PPS and one's a critical access you can't really develop an average for that too also I didn't want to make an average because wait times can be very fact specific there could be a doctor who's on L.A. which critically affects their wait time on March 1st 2019 but that doctor is back in action now or they could have been recruiting and onboarded a physician in April of this year so they can be so fact specific and then lastly there was an inconsistent use of subcategories so if the line item was primary care primary care can have lots of types of visits have a new patient an office visit, a physical exam and so there was this inconsistent use of subcategories nevertheless even with all these considerations there are some themes or outcomes which you can clearly see on this chart so this is these are all of the services that we asked about in alphabetical order and this line across indicates these are the services that we asked about and these are the five categories that were added so these are the ones where we might be under representing the services that are actually provided in the hospitals most of the facts specific circumstances that contribute to the wait time variations were workforce related so this is a theme is the workforce the wait times have been set from a point in time on March 30 so any of the onboarding efforts aren't reflected this is certainly true for a lot of Rutland's wait times all of these hospitals are on the right hand side of the little asterisk Rutland reported that several of these with high wait times they are actively recruiting and sometimes for many many years they've been actively recruiting so we don't have any goals for any of the hospitals except for the IHI goal of zero days for primary care for a specialty where we can ask the hospitals what their own personal goals are it'd be very interesting to know if they have internal benchmarks so again you'll see this in the recommendation that that might be something that we asked for so I'm going to advance from this slide because it's probably nobody can read it anyway this is sorry UVM 10 days percent of the patients are seen within 10 days because UVM and Central Vermont were not on the other side so this they gave it to us and on the medical order we resorted it into the percentage from 0% of patients are seen within the first 10 days all up to 100% of patients are seen in the first 10 days this is Central Vermont's version of that chart this slide is our kind of attempt to provide a system look we looked at the services that had the highest wait times and they are all specialty care services such as neurology, urology and ear nose and throat we did a time to do a system look for just or an average for just those services in particular and broke it up by critical access PGS hospital in New York and Central Vermont so for neurology the results are listed urology and ANT interesting we can see here that critical access hospitals have a lower wait time in some of these which begs the question about referrals what are their referral patterns so again it kind of leads us into many layers I should have started this presentation by saying that this report is presenting information it's not presenting conclusions it's a way of kind of identifying where do you want us to ask the questions or where would you like to ask the questions in an effort to connect us to the community needs we know that primary care addiction treatment are needs that are coming up in the community health needs assessment we did the same sort of analysis breaking it up by hospital type showing UVM and Central Vermont results so from this chart it looks like access to addiction treatment can be relatively quick whereas access to mental health treatment is not as quick there's a longer wait for that kind of treatment any questions moving on so our sort of analysis which I've touched on and again workforce continues to be an issue in a significant component of wait time specialty care is experiencing higher wait times mental health addiction treatment primary care all have higher wait times primary care is exceeding a goal of 0 days of very much available appointment some of the strategies are reducing wait times the hospitals reported some strategies are they're trying to improve their referral referral system so having UVM I asked them specifically they said that they're trying to centralize all of their referrals so instead of sending out a referral to multiple offices all at the same time and it could be sitting on a fax machine or it could be sitting in someone's inbox and they never really know who's going to respond they're centralizing it so it's all in one place and everybody can see it all at the same time so they're investing it's an investment but they're trying to get around these higher wait times through better referral patterns hospitals are developing better methodology for anticipating demand this is very difficult work but you can hospitals are trying to look at the demographics of their population to predict what demand might be some hospitals are reporting that they're putting their positions on call so that they have more coverage the doctor doesn't have to be in the office but they're available I kind of see this and I've heard this from hospitals and some of their presentations to the Green Mountain Care Board is sort of a short term solution because this has a burnout factor doctors also need to take their time off so these are some of the strategies for reducing wait time that don't require hiring somebody because they're such a workforce issue and I think that what you'll see from the hospitals are more of these creative solutions that reduce wait time without having to hire more providers and so as we move into 2020 what we'd recommend, I'm sorry as we move into July 1st and we can ask these questions ahead of time some of the questions you might want us to ask are what are effective strategies for reducing wait times right now we sort of collected them from the hospitals when they came through reports but we can be more proactive in asking those questions I have a feeling there's a lot of very interesting strategies for reducing wait times that don't require hiring hiring what are the hospital's internal benchmarks this will help us assess how they're doing sometimes having a long wait time is an okay thing you need to balance access to services first with what's appropriate for the community and how does the hospital determine oh I gotta have it myself how does the hospital determine the right balance of access based on service type and then again what we would monitor as staff when we see the budgets is any risks or opportunities that are identified that relate to patient access or wait time and any provider transfers, acquisitions or CONs that are related to provider patient access so any questions on that I just have one question I was curious if anyone mentioned telemedicine as a strategy for reducing wait times particularly in some of the specialty areas yes I'm glad you brought that up Robin I have it on my next slide to talk about COBLI did specifically you didn't know it's right on point COBLI did specifically but I think we should ask that to the hospitals because it is appearing more and more as a strategy for patient access that doesn't require hiring somebody that we should probably call that question out specifically this slide which looks very similar to the one you were doing this is a summary of all the recommendations and right here in my notes I said telehealth not on the slide for today but definitely relevant even today we were listening about how telehealth is a way for rural communities to access services it's good for the hospital it's good for the patient it's good for geographically diverse areas like Vermont with lots of rural communities so we might want to ask more proactively about that so staff will monitor CLNs provider transfers acquisitions and other requests related to mental health and substance use disorders for example we might see CLNs related to transitioning existing ED space and to safe and private areas for patients awaiting admission or transfer for mental health or substance use disorder we might see something in the budget about putting specialized staffing in the ED MAT treatment adding more and better people in the emergency rooms to help with these issues that are presented themselves in the emergency room and this is a summary of the questions that we already discussed for community health assistance patient access wait time and this is just kind of moving forward we will as staff as we move forward look at the list of considerations figure out how we can improve how we do our analysis how we ask hospitals for the information we would consult with the hospitals in that they're doing the work and so they have ideas of how it could be communicated better or more effectively and also just want to flag that there may be some interest in integrating with the Department of Health and the hospitals in the community health needs assessment not so much standardizing it but creating some system looks that would be helpful to elevate some issues out of the community out of the individual report there's 14 reports and they're very long elevating them out of the report and more into collecting the data in a way that we can do a system analysis so that is it and then the appendix just quickly all of the individual reports are listed on the website which that link went active this morning anyone was looking for those and then there's several charts in the back that kind of show each hospital that reported on a service type and where they are and then lastly the appendix sees some very helpful thank you to the Department of Health for guiding this it's a summary of each community health needs assessment for the 14 hospitals so if you were looking for the cliff notes version this would be it so any questions so I'll start off just by saying there's a lot of information a lot to digest but one of the key takeaways that I take immediately is that maybe we could be doing this better by trying to create some more consistency and I know you said we don't want to seek standardization but I'm wondering if a conversation shouldn't occur with the Department of Health with us with the hospitals just to try to see if there isn't something that we could agree on that would give us all better information in a more consistent manner what are your thoughts on that absolutely you know we are I can speak on behalf of the Green Mountain Care Board staff which is that financial staff we're always very careful about what we ask hospitals to report to us and we don't want to just add reporting requirements for the sake of adding them but something like this where they're already producing the data but it's not in a way that we can provide a system analysis I think we're losing out on hospitals and the communities might be losing out on an opportunity to develop deeper analysis and elevate the issues right now you really would have to pick up 14 community health assessments and read them to get a real deep understanding of what the issues are and develop your own analysis and if we could work together we could have more relevant reporting maybe we could work together maybe we could lighten by trying to make it very clear to people so we're not spending a lot of time trying to figure out how to report things like that I don't know it just seems like it might make sense if our staff, the Department of Health and the hospitals just had a sit down and just saw if there were any common goals I think it could definitely help some smaller hospitals too that don't have a lot of staff to do these sorts of assessments that they could leverage a methodology that's successful in another hospital there could be a a sharing of information the other thing I'll just add from previous work I've done in this realm is that something to remember is that the hospitals are doing community health needs assessments based on a very specific IRS requirement and so they're pretty well laid out and so asking anything additional that we might add between the health department well I absolutely agree that collaboration is key in making sure that we're developing metrics that make sense they're really only required to report what's required of them from the federal government which is something that we ran into in some of these conversations when I very first started at the board so two and a half last years ago we had talked with folks at the Department of Health about this theory issue I think it definitely would make sense just to regroup with the three parties and find out where we can make it more streamlined but it's one of those things and I think Michelle is alluding to that we're always, we have I think it's by monthly meetings with our VDH partners and this is one of the items that is always on the agenda but I support that but if the hospitals are on the table well I support yes being down with the hospitals I think it's a great idea okay so I'm going to direct you to make sure that happens yes thank you we'll make sure it happens questions from the board Jess so actually thank you so much I know how much work it took to try and summarize and condense and prepare for all the information we've received and I look forward to actually digging deeper into the hospital specific submissions one thing I would just add about and I like the questions that you're posing for potential follow-up one question I might add or think about and think about how we can think about is the consequences of the wait times so to the extent that there's patient impact are these, the patients that are you know we're seeing these long wait times are they on multiple wait lists and they're actually getting the care somewhere else or are they not getting care at all because they're such a wait list and then their health outcomes are compromised I mean there's a spectrum of a lot of the latter but I don't know how to unpack some of that what happens when patients are waiting on the wait list can they go someplace else or are they getting access elsewhere or not and do the hospitals know that what's happening so it's an excellent question and we'll think about how to ask that there is referral within the system and even to agencies or organizations that are not hospitals but we also know from that I'll use that mom's cutting chart again as an example that one of the barriers to service was wait time so people are not going to the doctor because of the wait time so I think it's probably a little bit of everything and asking the hospitals directly that question would help eliminate how they can get the consequences of the wait times but thank you other questions see now I'll open it up to the public for comments or questions Susan first of all thank you for that unbelievable amount of really good and very interesting information that was great one quick question is I guess I'm supposed to ask something new do you collect the schedule ages and are those available like me through the agreement with care board or do I have to get them directed from the hospital we do collect them and we do post them so they're part of, they're not labeled scheduled age, they're labeled IRS Form 990 so that's what you would look for on our website so there's a wonderful health think tank and I'm thinking on the name I might need a wheelhouse anyway they've done extensive writing on the community health benefit so what I'm understanding is that what the amount is supposed to represent is what the hospital would be paying if it wasn't a non-profit and so a lot of people in this room probably know that one of the first things Bernie Sanders did when he was mayor of Burlington was send UVM a tax bill saying hey guys, why don't you pay your property taxes since we don't think you're giving enough of that community benefit instead so that was a long time ago flash forward, affordable care act tried to corral some of this money because we all know that Medicaid can't pay for housing and Medicaid is really being leaned down to meet the needs of social determinants of health in ways that it wasn't intended to whereas hospitals can spend money on housing UVM we've seen in the state has some states have actually enacted statutes to try to get at this question that you're starting to ask which I think is a great spot on question how much should they be paying how do you measure it I know it's complicated but just even knowing what a ballpark or benchmark should be is it a percent of that patient revenue is it a percent of the overall budget what should it be so some states have actually passed legislation to direct the hospitals and they don't have 50 things that could be amount of care boards that they do with other mechanisms but to direct a certain amount of their budget on these community health needs my understanding from the IRS process is that once they have their plan they're supposed to account for the areas that they're not spending so let's say they've identified mental health right up on top but they spent all their money on fund runs or breast cancer awareness or something else good public health benefits but not mental health my understanding is they're supposed to account for that report those reports but also getting back to that shouldn't there be an amount have you looked at what other states have done to try to come up with an amount yes I have in trying to understand that financial investment I did see that other states are doing that they are required by state law to collect that information and you are exactly right about a lot of states are doing I shouldn't say a lot but some of the ones I was looking at they're looking at how much the state the hospital would have paid for the Vermont tax exempt and then they're looking at the schedule H to see if they've satisfied that requirement but we do not do that in Vermont that would be an act of the General Assembly to require that just a reminder that you have to have a positive margin to be able to make investments too other questions or comments from the public great thank you very much so at this time we're going to switch to a great review 101 presentation do we have enough chairs for our room or are you doing this in shifts I'm cool that has needed that has needed can we squeeze some more chairs up front because you know who wants to be down front it's actually planned that way because it's okay do we have everyone here I know we're on a schedule yes we do good afternoon my name is Amber and Amber Jaley I'm an associate general counsel at the Green Mountain Care Board and we are here today to do rate review 101 this should be interesting hopefully informative and how do I make this work okay okay so I'm going to start off by just giving a brief introduction from myself and this is my colleague Tom hi I'm Tom Croft and I'm an associate director of health systems finance so after we finish our brief introduction then we're going to hear from the office of the health care advocate and then we're going to have DFR and Diva also join us up here for a larger panel type presentation so some of the topics that we're going to cover today are what is the difference between rate review for large groups versus small groups and individuals what are the consumer trends and issues that the office of the health care advocate is hearing about what are the components of setting a premium rate increase I say increase but really could be a decrease also who regulates insurance plans and rate increases or decreases in Vermont what is the process for approving a plan or rate and implementing that plan and rate and how do other regulatory processes and the federal landscape impact rates so as I said our hope today is to provide some broader context we've had some large group filings early this year we have some current small group and individual filings that are pending currently so having said that we are not able to discuss any of the current filings that are pending before the board so I will just say that right now and our goal is to have it's important to reinforce that too because when we get to the public comment period it's going to be very difficult to ask questions that we can't answer so we could when we get to public comment limited to comment rather than to questions that would be great so that we don't fall into any rabbit holes yes I will also say that if you visit the Green Mountain Care Board's website on the rate review page you'll find information there on current filings there's also an opportunity to provide public comment there I know the office of the health care advocate also has a web tool for providing comment through their web page that gets forwarded to the board and then in addition to that we will be having our small group of individual hearings on July 22nd and 23rd followed by a public comment there so there will be multiple opportunities to comment on current filings and we encourage you to use those tools to do so so just a brief overview of what we're talking about today I am relatively new to the rate review world so this I know for me was very helpful to put our work into context when looking at insurance in Vermont so some important things to note these numbers are tiny so I know there are handouts if you want to look at them I've pulled out some of the highlights here this is looking at data from 2017 I don't believe we will have full data for 2018 until later this summer or early fall one of the things that you should know about rate review here is that we're talking about major medical insurance only which means that we're not talking about care supplement long term care vision and dental only plans disease specific plans for disability insurance so you'll see from this slide that you'll see the population of Vermont which was again as of 2017 and you'll note these numbers are rounded to the nearest thousand population of Vermont was about 623,000 people and then you'll see if you look at the insurance breakdown again this is just major medical insurance only you'll see that the biggest chunk of the market is in Medicare and Medicaid followed by the self-insured market and then followed by the insured market which is where the board has jurisdiction and then there's another category for non-Vermont insurance coverage and then the uninsured for people who are not familiar with the term self-insurance this is where the employer provides the benefits to employees using the company's own funds which means that the employer rather than an insurance company is going to assume the risk for payment of the claims from the employees and just so you have some idea of where this data comes from it's from multiple sources it's from the annual statement supplement report the Vermont household health insurance survey the Vermont health care claims uniform reporting evaluation system also known as V-Cures the department of Vermont health access and the Dartmouth Institute for Health Policy and Clinical Practice so now that you have a basic understanding of where we're going to go today I would like to invite Mike Fischer up Good afternoon It's good to have a few minutes to speak to the board and to the public though to healthcare focused people about the healthcare advocates role in insurance rate review and some of the patterns we see some of the cases that motivate us so just quickly it was good for me to take a moment to re-read the statutes to and to spend some time reading through some cases so that I could prepare for this but also it was a good exercise for me the HDA was created to act on behalf of Vermont health care consumers that plays out mostly in our role helping individual Vermonters though that statement is broader than that that is what sort of backs up the call center and our work supporting about 4,000 cases a year of people who are in some way stuck in some part of the healthcare system in some way not able to get the care they need the statute also gives us the opportunity to represent the interests of the people of the state in cases requiring hearing before the Green Mountain care board and that's really the section of statute that backs up our role in insurance rate review and sort of brings us to the table so one of the obvious questions is how did it come to be that there is an independent consumer advocate and an independent regulator both at doing this task and some people may say boy don't you have a similar role or the same role in some ways and I think the answer is yes and I know I think that it's an important structural difference that the advocate doesn't saddle with a lot of the responsibility that the board has the advocate gets to argue in a little bit more of a pure way about the interests of the people as we understand it as we see them and to provide a bit of a counterbalance it's also back to the first thing it's also I think structurally very important that we have an individual advocacy role and a public and a policy advocacy role they it provides a bit of an interesting tension and I'm going to call it a bit of a tension in the past I've often said how we're at our best when those two roles inform each other but today I'm reflecting a little bit on how those two roles are not always sometimes incongruous not aligned drive people and drive us in different directions and I was thinking that I would walk through a couple of case examples where that becomes clear and I think in a real way this became sort of in my face in the open enrollment for the silver loading open enrollment this past year really smart people really smart policy people sat down and we did the very best job we could to develop a plan that would work for Vermonters and and it was the best option and we did it and our partners all the parties worked hard at it and we saw about half of the Vermonters who could benefit take advantage of it many many Vermonters didn't act in the way that we presumed they would and that got me thinking about just how different the perspective is as a consumer than the perspective is as a healthcare policy wonk and I don't mean that in a negative way so so when so and if I say any identifying information about a client I have changed those details and like town or name or disease or anything like that so when we see somebody who is seeking better coverage when they have a healthcare need the general understanding of that is that is someone who is gaming the system that is adverse selection that is somebody who has sat on the sidelines until they needed care and we in healthcare policy circles poo poo that but when you put that in the context of a young pregnant woman who has a catastrophic plan and is seeking a better plan so that she can get the best prenatal care she needs it creates a whole different meaning and that also plays out many times in the cases we see of people who also who don't have coverage and who don't have a life event that gives them a special enrollment period so similarly when we hear about people who are not following doctor's orders who are not doing what their doctor asks we would often hear people say that this is someone who is resistant to care resistant to treatment when we put that in the context of a middle aged guy from Rutland County who's a carpenter who's at believe it or not 401% of the federal poverty level is buying their insurance directly from their from the carrier and who has who has a chronic condition who's being asked to go to the specialist regularly at $75 a pop for the silver plan and who calls us in frustration because he just can't do it so I'll go a little bit deeper into this one because we would quickly recognize the opportunities for this individual about how they can qualify for some better supports but there are situations where the intricacies of family law and health care law don't align and make it very hard for people to do what might seem obvious to those of us who are in the middle of this and so then lastly there are, I do read a pattern of cases where somebody while they're happy they just got a promotion or they just got a job and they're happy that they're going to be able to leave for a decade or they're going to be making more income and be able and maybe their employer's offering them insurance but when they look at the details and they see deductibles of $4,100 to $2,800 or $7,600 to $15,200 I'm reading the deductibles from silver and gold standard plans there and they do an analysis of what their likely care is what they experience in their lives and what their income is I recognize they're making a financial decision not a health care decision here but many people do and it would be sacrilegious as a health care policy wonk for me to say I support that decision to not buy insurance and to pay out of pocket for their needs so I won't say that because we all understand the risks of such a decision but I will say I understand that choice and for many Vermont families while it might look like a bad choice to health care policy folks it's a reasonable choice so we see cases like that so with those cases in mind that we have a role in arguing on behalf of Vermonters before the Green Mountain Care Board and in other places and then I think the last thing I want to say out loud that I know I've said before and I just think it's important to say again and again and that's that and I think many of us in this room experience this reality that we have an opportunity to comment on pieces of the health care system in the and sometimes very specifically about that company in that piece we all know that there's no insurance rate without a hospital commercial rate and we all know that that the many pieces of the health care system impact each other and sometimes it's hard to say that out loud when they're in the middle of an individual case but but often our perspective and our frustration is broader than the individual thing we're arguing about so thank you thank you we're going to take a moment to add some chairs are we going to add chairs or are we going to swap out both I think so moving back to some process and again I just wanted to thank the office of the health care advocate for taking the time to come here today obviously the consumers experience is an important background to what we do here today and what the board does as a regulator so thank you again Mike for coming and moving back more into process I wanted to provide some additional context about large group and small group and individual plans and how those are rated I have a chart here which just has some of the basics of the differences between the rate review for a large group versus a small group as I mentioned earlier just from a timeline perspective we do receive large group filings in January, February, March and later in the year whereas for our small group and individual plans these are typically in early May as you will hear there is a lengthy process that involves multiple departments that needs to occur in order to have everything in place for open enrollment I'm going to discuss a little bit later the differences between experience rating and community rating but just be aware that there is a difference in the type of rate that the board approves for for those two different sections and the effective date varies for large groups the effective date for rates will be January 1st for small group and individual plans as many of you may know there are plans the plans for large group are offered outside of the exchange small group and individual there are some on the exchange and then also some outside the exchange which include reflective silver plans and then subsidies are not available for large groups or for small groups but within individual plans offered through the exchange there are subsidies available and then just again to take a look at the scale of what we're talking about during this rate review process for large group and this is the most recent data that we could have for the for the 2019 enrollment year about 17,000 covered lives for large groups and current 2019 is about 75,000 so this is a big chart this is a nice visualization on how to look at what the components are of a rate chart change, that's a safe change rate change and or premium well I just want to clarify that this is not how, this is not necessarily how these components are within premiums but what we're talking about here specifically today is a change in that premium so I just wanted to highlight a couple items from this chart it has a lot of information which I'm not going to go into in great detail but I would like to point out a couple things first is that the claims branch here up at the top comprises about 85 to 90% of a rate change and so it's important to keep in mind when you're looking at this chart that these components are are weighted differently so if you were to have a 1% change down somewhere at the end of the chart over on the right side that wouldn't be a 1% necessarily reflected once you finally get to the rate change as a total and I also added in a orange box up here towards the top just to highlight something that we're going to talk about a little bit later during the presentation for regulatory integration this is where approved hospital budgets come into the rate review process so we will circle back to that a little bit later and then Tom had any comments about some of the other components down here no I think we'll get into that okay so here looking at looking at the timeline and regulatory roles of the people you see here before you you'll see that as we go through rate review there are responsibilities within different departments you'll see that health plan design and compliance with federal parameters is done by Diva who will present a plan design and recommendation to the board who will approve or modify and approve you'll see that form filings go to DFR and rate review will consist of both work from DFR as well as the Green Mountain Care Board once a rate has been approved Diva is going to certify plans and then Diva will also work on open enrollment and again compliance with federal parameters related to open enrollment I noted at the bottom you'll see some of these steps are just for small group and individual plan rate review that's due to some heightened federal regulations around those types of plans so a very high level overview of large group rate review and you'll see this process in many ways mirrors what you'll see later for small group and individual but there are some differences again the timeframe is going to be different in terms of when the when the filings are submitted to the board the board has 90 as with all rate review the board has 90 days to review and modify approve or deny a rate and some additional details here I think I know that we're going to go a little bit deeper into process with Diva so I don't know that I'll go into a huge level of detail here since much of the process is the same but I will say for large group you don't often hear about them as much because it's often the case that the parties waive the hearing and so the board will receive memorandums instead of having a hearing and again keeping in mind that large group rates affect certainly 17,000 covered lives and one important thing to note that I mentioned a bit earlier was manual rate someone on the phone is maybe a brief description of how the board only approves a manual rate for large group filings because large group filings are experience rated and what this means is if you think back to that basics of a premium component page that we showed earlier when we're looking at a manual rate you have all of the components of a premium that you saw earlier however the board only approves one manual rate for a large group filing the insurer then goes and takes that manual rate and applies it to specific large groups and based on that large groups previous claims experience will either adjust it above or below or keep it the same from the manual rate to account for that large groups particular experience this is not the case in small group and individual plans so that is something I will talk about a bit later when we talk about community rating for small groups and individual plans that is an important thing to note while we're here I'll also say that when the board issues its decision and like with all rate review filings the board has to consider a statutory criteria and I will just read that briefly because this is information that you can see in the board's past rate review decisions if you'd like to learn more about how the board evaluates the rate the board shall determine whether a rate is affordable promotes quality care, promotes access to health care, protects insurer solvency and is not unfair unjust, inequitable, misleading laws in the state in making this a clear of things that are most relevant to providing context for a big review today so to start off here the annual process for analyzing and preparing the QHP plan designs begins in October it may surprise some of you that for the 2020 plan year we begin this process in October of 2018 so we're kind of midway through that process right now and just to let us know qualified health plans are what are available to individuals in small groups so that's when everyone is walking through the two columns we're now squarely on the individual small group side that's right exchange market so the first piece in that time frame of October through January I convene a stakeholder group that consists of representatives from each of our issuers from the health care advocates office from a staff from the Green Mountain Care Board and staff from DFR Department of Financial Regulation others including myself from DEVA and of course our contractor actuary who has the professional guidance through the process financial analysis and so forth so we in the fall take a look at the guidance that's provided from the feds more on that in the next slide I'll come back to that and we have the task of making the difficult choices sometimes of making plan design or cost share change choices to keep the qualified health plans at each metal level in compliance and again more on what that means but that's our the and we have a whole series of meetings in that time frame in the fall leading up to a presentation to Green Mountain Care Board in late January along with our professional actuary we present the proposed plan designs for each plan each standard plan I should say offered on the exchange and a standard plan means that the same plan design is offered by each of the issuers on the exchange so if we cross the shield and MPP's platinum plan has the same plan design for example in the standard category present that in one meeting and typically return for a second meeting with the board for follow-up questions for response to public comment and then for the board's approval as proposed or with changes so that's what happens in February time frame and then in a few weeks following that approval our actuary provides a WMP document as a roadmap essentially for the issuers to prepare their standard plan designs and that's communicated through our actuary to each of our issuers sorry I think one of the key points we want to make is how much of this is driven by federal regulation so we're the design process sounds exciting but it's really about matching the plan designs into a calculator that's provided by the federal government related to the actuarial value so Dana will walk through what this looks like but just to be kind of clear that a lot of this is coming from the federal source. It's exactly right we have very tight guardrails that we need to work with in to keep those plans compliant so the federal guidance I refer to is that notice of benefits and payment parameters there's a lot of information in that and that's the guideline that we need to follow to present and maintain compliant plan designs included in that document is that federal ABC the actuarial value calculator that has it's basically a tool where we can through our actuaries they run the plan design through this calculator and the result of that calculator is what is the actuarial value of a particular plan actuarial value for those who may not know that is a for example a silver plan at 70% actuarial value means that the plan covers 70% of the cost of services on average leaving 30% for the individual to cover 70% so the richer the plan for example a platinum plan covers 90% leaving 10% to the individual so higher premium what changes each year in the calculator is the cost of those services within the calculator so the same plan looked at for 2019 and 2020 may no longer fit the requirement because the underlying costs have been increased according to the decisions at the federal level of what trends should be applied for medical services and pharmacy also the services included within the calculator may change not every service is included most are but that may change a little bit from here it's defined what the acceptable range is for each qualified health plan at a certain level typically it's for example a gold plan at 80% has an acceptable compliant AV range of minus 4 plus 2 so if they're at 80% they can go down to 76% or higher 82% so the max amount of pocket has provided another policy information that we need to analyze and bake into our plan designs to ensure that they're compliant so as I said those are sometimes difficult choices guidelines don't leave a lot of wiggle room and there are a limited number of factors that can be changed within a plan design to bring a plan to the AV range timing is that the notice of benefit payment parameters the draft is typically released in the fall around the November timeframe not always and if it's later that can throw off the rest of the timeline such as this year we had to make some adjustments but I'm hoping that this is helpful context to start off the process for certification okay so I think we'll turn it over to Emily Brown I'm the director of rates and forms at the department of financial regulation so I will be talking about the qualified health plan form review so after Diva goes through the standards decides what those should be gets them approved by the board the carriers then submit their forms to the department of financial regulation so under 40 62 DFR has the ability to review forms for major medical and as Amron mentioned before the standards for the rates in statute are the same for the forms meaning that they can't be unjust unfair inequitable or misleading so when we are reviewing contract language in those policies we're applying those standards as well as other benefit standards that might come from the state or the federal level so the first thing we obviously do is we make sure that the insurers are licensed and in good standing in the state we obviously DFR is charged with company licensing as well so that goes into our process to making sure that you want insurers offering these plans who are able to pay claims and who don't have any actions against them by the department the next step would be to look at all the benefit and contract standards within the forms so we use title 8 for that but we also use title 18 which is the healthcare administration chapter and that also has policy provisions which were required or which the insurers are required to include in the forms other parts of the benefit standards are the essential health benefits and these are defined by the benchmark plan which was adopted by the Green Mountain Care Board at the implementation of the ACA each state has a different definition of what essential health benefits can mean so Vermont has a specific definition that might vary from other states in the country we also make sure that the state mandates are included Vermont has several state mandated benefits in title 8 which insurers are required to provide to policy holders you have the federal mandate so you have whether it's coming through the payment parameters notice or other directives from the federal level we want to make sure that insurers are providing all the benefits that are required at the federal level as well and then incorporating any changes that come year to year through the QHP standards working group that Dana alluded to at the beginning other things I thought were interesting that we look at is the annual limitations on cost sharing so these come through in the SBCs of the summary of benefits and coverages we also look at mental health parity which come in quantitative measures but also non-quantitative so for instance if the plan had network tiering we want to make sure that they're providing the mental and substance use disorder services at the same rate that they are for the physical injuries and we also look at the network adequacy and this isn't necessarily part of the form review but that is a requirement we have for all managed care organizations or insurers operating in Vermont and those I2009-03 contains those consumer protection and quality requirements standards and I'm going to speak a little bit about DFR's solvency role that Amarin mentioned at her during her presentation so DFR is charged with company licensing so for any domestic insurer we are required to look at whether they are solvent-enabled to pay claims so for every major medical rate filing that is filed with the Greenmount Care Ward we provide a solvency analysis and that applies to large group as well as the small group and individual plans and it varies depending on what type of insurer is domestic or foreign so based on how states regulate insurance companies if it was a foreign insurer we would rely on the state where the insurer was based to provide us assurance that that insurer could cover claims and operate in a solvent manner. If it was a domestic company then we DFR would be charged with doing the solvency analysis and making sure that the insurer had adequate surplus to pay claims so I just also wanted to talk a little bit about what goes into our solvency analysis so I think solvency can usually be explained in the context of adequate surplus so what that means is that you have to have a good amount of money through adequate premium to pay expected claims and adequate expenses to operate as well as when it's appropriate to contribute to your surplus and certain factors that can contribute to an inadequate surplus could be if you had inadequate premiums so if you weren't charging enough money to cover your claims and expenses. Adverse medical trends so if there was a specialty drug that came out that increased costs or a period of higher than expected experience in medical claims that could also affect and ensure solvency and as well as a volatile regulatory environment so when there are changes either at the federal level or the state level that can have a direct impact on and insurers solvency and basically affect their surplus and then also something I think that some people don't think about as an increase in membership so when you have more people enrolled all of a sudden your surplus where it might have been adequate for certain amount of people who you covered once you are covering more people you need to have a greater amount of surplus to make sure that you can pay those claims and expenses. So moving back to the board's role during great review of small group and individual plans this process looks a lot like what you saw on the large group review slide I'm just going to go into a tiny bit more detail here you'll see that we mentioned that the insurers provide an actuarial analysis to support their proposed rates the board has an actuary who reviews that analysis and does some of their own analysis and you'll see that there are back and forth questions and answers between the board's actuary and the actuaries at the insurer those back and forth questions are for the most part posted on the board's website if you're curious to see what those look like in addition as Emily was just mentioning DFR provides its analysis to the board about the insurer's solvency and then at least for the QHP plans hearings are usually held that are not usually waived and that's usually towards the end of July this year it's going to be July 22nd and 23rd and at the hearing you'll hear from insurers you'll hear from DFR you'll hear from the office of the healthcare advocate and then afterwards the board will issue its decision as Emily mentioned there are the same criteria that the board is required to look at as in large group they will also look at for small group and individual plans and some so a couple things to know about the market generally for small group and individual Vermont has a merged market for small group and individuals meaning that there aren't different rates for small group or a certain set of small groups and individuals so the reason behind having a merged market is that with multiple markets especially with Vermont's small population we have a lot of volatility between groups and it makes it very difficult to predict what the experience is going to be so it's difficult to predict what an adequate premium would be so by having a merged market of a small group and individual is that you'll have a more experience that is more predictable because larger pools of experience are more stable so in addition to that something that I touched on briefly earlier is that our small group individual merged market is community rated which means that when I was discussing earlier about large groups where the board approves a manual rate and then the insurer can adjust the premium that each large employer has to pay up and down based on the large employer's past experience that is not the case in the small group an individual market everyone receives the same rate so when the board approves a rate you'll know what premiums are going to be charged to small groups and individuals I'm going to pass it over to Tom briefly to talk about what the impact of how Vermont does community rating when people try and compare Vermont to other states because there are some important things to know when you see comparisons between Vermont and other states that are from community rating thank you Emron as the QHP rate filings come in as they're doing now there invariably will be the want for the need for different organizations to compare rates state by state all these organizations are Kaiser and Alvera the thing to know is that most of these comparisons especially when it comes to Vermont are not on an apples to apples basis first the usual comparison is second lowest cost silver plant at a specific age so if they're using age 35 or 40 again Vermont's community rated so all ages are the same other big factors is they will use non-smoker rates so they'll pick out lowest cost silver plant age 35 non-smoker in Vermont we have tobacco blended rates so it's the same for a smoker or non-smoker so just really to emphasize a lot of those comparisons are not on an apples to apples basis so now we're back to Diva for the other bookend but I did just want to say the timeline just again to highlight some of the federal influences for rigor views also set federally generally it's more kind of permissive than state law but we do have to have final rates for the exchange generally in August which is how it has worked here traditionally as well so once the rates are final then we step in with this final step so I just want to add too that this is so following plan design approval following the form review and approval from DFR following rate review and approval the ultimate decision on QHP certification which means selection to be offered on exchange is given to the Diva commissioner so you know kind of hold back for some big surprises but it's just like Addy said it's a bookend process and it's where it begins and ends with Diva to make the decisions about which all of our health plans should be offered on the exchange so I think I'll just give you a picture here of the activities that happened after final rate approval and so I'm talking about activities that are highly focused from Diva but I want to wrap up the issuers focusing on a lot of the same things at the same time it's a very busy time to make sure that all of our information in our respective systems are updated accurately and will be in alignment in preparation for open enrollment so right after rate approval there's a lot of preparation for public facing materials on our websites and information on paper and we have a plan comparison tool that all needs the updated plan benefit and rate information to be in there exactly right so that the consumers shopping for plans their existing enrollee or a new enrollee can see what one plan is compared to another accurately and there's quite a bit of work to get the updates into our respective systems again to guide consumers through also in August to September time frame and in the middle there that August to September step of updating the subsidy calculation factors that's for people that are rolling through the exchange there are several factors that go into subsidy calculations some are received from the federal government such as the federal poverty levels something like the applicable percentage is updated each year and then something that depends on the rate approval is the second lowest cost silver plan that's the benchmark that's plugged into the subsidy calculation all of those things need to be available and updated accurately and then in September we tested going within the exchange and between the exchange and the issuers to make sure that all of our information and numbers are in there accurately so certification is another step that's required federally of DEVA the timeline standard on the federal level is actually October for final certification and re-certification but we work really hard to do that as early as possible in September so that there's time for all this stuff to happen so that the open room can launch as federally required on November 1st so that's the overview of the process now I'm going to move on to some other areas that may affect premiums and rate changes one of those items is looking at regulatory integration and so I will just preface my comments on this with this work is ongoing this is regulatory integration is something that we as staff are taking a closer look at so that we can fully understand how the boards work in one regulatory area such as hospital budgets is going to affect rate review and vice versa and so first I wanted to just point out where we are right now in terms of regulatory integration and our understanding of regulatory integration currently you'll see from the orange box of here this is the box where we're looking at approved hospital budgets and so that will be a component that's looked at during rate review an area that we are further exploring is utilization and how how we can get a better understanding of how data and utilization projections that occur during hospital budgets can better inform the rate review process and this again is some ongoing work it is important work because we estimate that about 50% of allowed medical claims stem from services and providers at remand care board regulated facilities so we can see that there's a connection here and there's data about both through rate review and through hospital budget review that could be useful in informing the rate review process but how that can happen is something that we're still exploring so right now we have been looking at ways to better integrate year-end hospital performance into the rate review process and we're also looking at how to monitor the commercial rate and PR decisions made by the board in the hospital budget process how to monitor the flow of those into the rate review process so having said that we recognize that there are some challenges in trying to go about this task and one of those challenges is when we're looking at integrating data from these two different processes we see that the services that the data covers is different right in hospital budget you're looking at a Vermont hospital budget whereas in rate review you're looking at Vermont facilities generally not just hospitals you're looking at costs from independent providers you're looking at retail pharmacists costs so there's a lot of additional services that are within rate review that won't necessarily be reflected within the data that you get during the hospital budget process similarly when we're looking at the patients and information from people during these processes in hospital budgets you're looking at patients who come from anywhere and everywhere into a hospital and receive services they could be Vermont residents, they could be non-residents whereas in rate review we're only looking at Vermont residents so there's overlap again in these areas but they cover different segments of populations then when we're looking at further difficulty here is looking at the data itself in terms of its time frame we're looking at hospital budgets we have data from the prior calendar year we're looking at rate review because of the claims lag you don't have the full calendar year data available during the rate review process so again much of the data overlaps but is different and in terms of how hospitals report information during the hospital budget process in terms of what categories and how what categories of information are provided and also how those categories of information are described differ from how we receive information during rate review so not only is the information different but the format of the information is different so sometimes it's hard to unpack the data in a way where it becomes meaningful to use as part of informing a different process so I will just also add briefly that I haven't that this is focused primarily on the hospital budget process because these are two areas where the board you can see areas where we need to look into this further I have not really touched on the ACO and how that plays into here there are some regular integration areas there but I will just say I know that the ACO has contracts both with providers and insurers so there are some integration built into the contract process and so for right now and given that the results for the commercial program results for the ACO for 2018 will be available for one to later this year our focus is currently on for today's presentation is on the hospital budget process and how that could impact rate review passing it to Tom just to clarify that the hospital budget here is on focus to September thank you yes so there is that difference also different budget so other areas that impact rates both the federal and the state landscape I'm going to talk briefly about some state laws that are the result of some federal changes the first one being the individual mandate or more precisely at the federal level the federal financial penalty ended and while the federal mandate remains without a financial penalty there was some concern that there would be a negative effect on enrollment in Vermont so first in 2018 there was Act 2022 which created a state individual mandate for health insurance coverage it's effective January 1st 2020 there is no financial penalty and then this past legislative session H524 which has passed both bodies but has not yet been signed by the governor or passed into law establishes a reporting requirement for the state mandate so that individuals who file taxes are required to check off the boxes saying that they had coverage for each month of the tax year in terms of the individual mandate like all federal and state changes during a rate review process the board would look at would use actuarial analysis and projections to see whether there would be an impact on enrollment or a particular rate filing another example of a federal change that has created a state change which may impact rates is the loss of the cost sharing reduction funding which was in late 17 this would have resulted in significant premium increases for 2019 and 2020 plan years to have the legislature not acted in to create an option for off exchange non-QHPs these are called reflective silver plans which allow for silver loading of QHP premiums this is a very detailed area so I won't go into the weeds on this one all I will say is that the loss of federal funding created the need for a state law which gave the state more flexibility in how they were going to address the potential for a large premium impact so as a result we had Act 88 which allowed the state to create reflective silver plans in order to increase subsidies within to silver load within the exchange and increase subsidies and minimize the impact on premium increases going forward there is some concern that perhaps silver loading will not be allowed after the 2020 plan year so this past legislative session with Act 89 there is now the option for more reflective plans off the exchange and the board has the authority to approve those off exchange plans and ensure that to the extent we are allowed to continue to silver load that we will do so because that is where we will receive subsidies and have the least impact on premiums I will be talking about association health plans just for background association health plans have been around since the 70's when it was implemented at the federal level association health plans are essentially vehicles for employers to group together to buy health insurance so these plans have dual regulatory authority meaning the feds and the states have the ability to regulate recently last year in June 2018 there was a DOL rule which expanded the use of association health plans and made them more accessible for small employers and individuals and to be able to buy health insurance so when I say pathway 2 I am referring to the new pathway or the new way the new association health plan model that was implemented last year in response to the DOL rule DFR implemented regulations regulations for fully and self-insured MIWAs and AHPs AHPs are a type of MIWA and then recently in March 2019 the district court vacated the department of labor's rule so currently we are in a state where the department of labor appealed the district court's ruling but did not request to stay so officially the DOL rule is vacated for the time being and going forward the association health plans operating Vermont for plan year 19 can continue to operate with the new coverage for plan year 20 so DFR does have guidance on this which is not on our website yet so I know all of you were very eager to check your phones for that but it will be published hopefully shortly and this essentially relays the federal guidance that was issued I believe in the past few weeks that no new association plans for plan year 2020 and existing association plans that were formed under the department of labor rule so the pathway to associations cannot enroll new members for plan year 19 as well as cannot advertise so next I'm just going to go through some pending federal litigation that I think expands a little bit on what Ameren was discussing and why a lot of state action has been happening especially in the last legislative session that are currently working through the courts that I'd like to point to and they all address different parts of the health care landscape so the first one is Texas BUS and this is the case challenging pretty much the whole ACA so it was started because the individual mandate penalty was zeroed out in the tax cuts and job acts and essentially there was a challenge saying that without the penalty the standalone mandate was not supported by the commerce clause and therefore was was invalid the individual mandate was invalid and then saying that the other ACA provisions were not several or the individual mandate was not severable from the other provisions of the ACA so therefore the whole ACA needed to be struck down and the defendants argument is that the individual mandate penalty remains it's just zeroed out right now and that if the individual mandate as amended is found to be unconstitutional it is severable from the rest of the ACA meaning that the provisions such as guaranteed issue and community rating would still exist so the current status of that case there was a district court opinion saying that the individual mandate is essential to the ACA and cannot be severed from the remaining provisions so essentially striking down the whole ACA and currently I believe there are state AGs appealing this to the Fifth Circuit the next case is New York BUS which has to do with association health plans so this case challenges the DOL's ability to implement the rule which I discussed earlier and essentially argues that the DOL was too expansive in its rule and therefore was not able to expand the use of association health plans as it did that rule that the district court vacated the DOL rule and essentially said that it was an N run around the ACA because a lot of association health plans do not have to comply with ACA requirements the DOL has appealed the decision to the circuit court of DC but it didn't request a stay so the rule is still vacated as of now and the DOL has issued two guidance letters saying that there is no comfort moving forward for association plans to move forward for 2020 the last case I wanted to talk about was having to a short term limited duration insurance so when the DOL put out the association health plan rule they also issued a rule on short term limited duration insurance and this was previously an insurance that people could use in between jobs it was limited to three months in duration it was not renewable the DOL expanded the use of short term limited duration insurance for up to three years so it essentially interpreted the word limited duration to mean up to three years and this is currently being challenged the plaintiff's argument being that the interpretation of limited duration is three years was not within the agency's discretion the defendant's argument is that the congress didn't define short term limited duration they were leaving it up to the agencies and therefore they should be able to expand the definition to 36 months and that case is still relatively in the beginning phases there have been oral arguments and it's currently pending in the district court thank you everyone for your presentations I've put up some resources here so you can learn more about rate review on the various sites that included the office of the healthcare advocates website as well as DFR, DEVA and of course the board's rate review page that concludes our presentation I think if there are comments about how this was informative and helpful and other areas where information would be useful to the public I'm certainly interested in hearing those comments as I said we can't really talk about any current filings but we do hope this was of use for people going into the rate review season if you will for QHPs this summer as well as sort of a preview on the board's work for regulatory integration and how that work will continue moving forward so thank you again for having us we have a couple of questions Michael will roll me out of order but Tom you mentioned that we had a tobacco blended state and what made that decision to be a tobacco blended state I will have to look into that I'm not exactly sure what I came from I would appreciate that I'd love to know if it's some federal or state statute that has to be tobacco blended under the ACA I do recall what Robin probably remembers a lot of the fight that we had in the legislature years ago to get a ban to put into statute that would allow for a different pricing so that's why I'm curious it comes back to my past activities we'll look into that secondly Emily on your slide it might make jump in quickly on this one you have no new members and I'm curious if that means no new attributed life spirit to the plan or if an existing employer could still add new employees so that's a good question so existing employers could add covered lives so for instance if someone got married who was employed their employer was a member of the association they could be added to the health plan but the association cannot accept any new employer members at this point so if a company approached the association and wanted to join they could not do that so it should be the power could be I don't have control of so questions from the board Tom I have one quick review your question last winter I think it was Agatha and Sean she and put together this very nice chart that kind of showed the cliff that the healthcare app gets in its presentation and this is kind of looking back at the 2019 with some fairly steep angles that confront people should their income go up and just a couple of them are when you're below 400% poverty with all subsidies etc for a couple the low-cost bronze plan is 2.73% of income and then when you cross that line above 400% poverty jumped to 13.8% of income so that's a pretty steep issue and I had asked last February if you folks could kind of put a price tag on the improvements from 400% of poverty to 450 and 450 to 500 so we just get a sense of what that price might be fully understanding that global commitment might fill that because of the waiver restrictions so I'm just asking you know where that stands at Diva and I think what we said this winter was we definitely share the concern about the cliff and that population of the unsubsidized individual market so we would love to chat with you about what it is that would be useful to see I mean I think that we have some ideas about how we could address that group and I know you were looking at something that is kind of a version of expanding the Vermont premium reduction into that group so I think we just need to talk a little bit more about what it would be what would be useful to see if you could do that sooner rather than later I would be sure and I don't think she's here anymore but it will be Ina Backes who's our director of health reform who is available to talk about that open up the public for comments who wasn't sure Sarah if you were scratching your head or raising your hand I have only one comment it's on the chart that you have that shows all the components of the rate change when you have the non claims components you have other and I would write very specifically regulatory or statutory changes that impact the plans or the coverage offer because I think especially after all the discussion is subsequent to that significant component of rate changes so just to be explicit you captured it there but how was it thank you let's see so I want to thank the panel it was very informative thank you very much is there any old business to come before the board seeing none is there a new business to come before the board seeing none is there a motion to adjourn so it's been moved and seconded to adjourn all those in favor signify by saying aye any opposed thank you everyone have a great rest of the day