 Good afternoon everyone. My name is Kevin Mullen chair of the Green Mountain care board and I'll call this meeting to order The first item on the agenda is the executive director's report Susan Barrett Great. Thank you, Mr. Chair. Good afternoon I have a few additions to our agenda for this month as well as some Public comments that are ongoing that I'd like to announce first and actually to start as a as an update I wanted to let folks know that on Monday, June 13th We had our general advisory committee meeting and at that meeting we discussed the hospital sustainability report that the board did for the legislature and also Reviewed Act 167 which was s285 that became law recently I just put a plug in for folks who are interested in coming up to speed on the work that the board has done on hospital sustainability and now the new legislation coming out of the legislature Act 167. It's a really good update and most Important is the comments from the advisory. They were incredibly helpful. We were we were honored to be joined by some folks from AHS as well So they were listening in on the conversation and of course we've shared that feedback with them as we are Collaborating closely on Act 167 with the agency of human services So that's really a plug on a great meeting and and a thank you to our general advisory committee members. I Also wanted to announce that tonight the primary care advisory group will be meeting And that starts at 5 30 via teams and now I'll just review The open public comments just to remind folks if they want to comment and on any of these items before the board First the board is currently accepting public comment on the Vermont information technology leaders vitals budget This was presented to the board on June 8th We'd ask that you submit public comment before close of business on June 17th So that it could be considered ahead of the Green Mountain care board staff Presentation and potential vote scheduled for next week June 22nd the board is also Currently reviewing the FY 23 accountable care organization budget guidance and certification form the Medicare only ACO guidance was reviewed last week at the board a meeting and then this This week the certified ACO guidance and certification form Will be reviewed for with the board Materials can be found on our website and then also we'd ask that folks comment by close of business June 20th in order for the board to consider those comments before its potential vote next Wednesday On Friday May 6th the board received and began its review of the proposed rates for major medical health insurance plans offered to individuals families and small businesses in Vermont in 2023 Including plans offered on the Vermont on Vermont health connect The board is accepting public comment on these filings We open this comment period on Monday, May 9th, and it will go until July 21st at 1159 p.m The comments may be submitted electronically through the rate review website on the Green Mountain care board website by email to GMC be dot board at Vermont dot gov by US mail to the GMC be at 144 State Street in Montpelier or by phone at 802-828-2177 All of this information is on our website and please submit comments on those very important plans And then last but certainly not least the board has an ongoing public comment period Regarding a potential next all-pair model agreement with the federal government We asked that you'd share those with the board and that we will share those with our Colleagues at the agency of Human Services and the governor's office as they are leading the negotiations on the next model and That is all I have to Announce and report out today chair Mullen back to you Thank you Susan the next item on the agenda are the minutes of Wednesday, June 8th. Do I have a motion? Move seconded It's been moved and seconded to approve the minutes of Wednesday, June 8th without any additions deletions or corrections Is there any discussion hearing none all those in favor of the motion, please signify by saying aye Any opposed, please do so by saying nay Let the record show that the motion carried unanimously And at this point Susan I'm gonna throw it back to you to tee up the discussion on the UVM health network mental health integration So Susan Thank you again, mr. Chair just I wanted to give a little background before I turn it over to the folks at UVM HN so I wanted to I Actually was the one who asked and of course worked with cheer mullin and asked The UVM HN folks to come before the board I had seen this Presentation given at the mental health integration council meeting a couple of months ago Just by way of background the mental health integration council is a statutorily prescribed Group that the Department of Mental Health is running. It's an excellent group that that that is Trying and it's a real real large mandate, but to try to integrate mental health Into primary care and and all sorts of care within within our health care system So I heard this presentation I thought it would be really helpful for the board to hear this presentation and also the general public and it's It's it, you know the the work that even UVM H and it is doing in Terms of their mental health integration in primary care. So I will turn this over We have dr. Bromstead. We have dr. Sara Pulaski and we have Clara Keegan I believe and then also Maureen Lehi who will be presenting to us and I'm Thinking I'll turn it to you dr. Bromstead to introduce your team Thank you so much. I'll Let each of the team members introduce themselves when we get there I'd like to Thank the the board for their time and Susan for your interest This is great work and my job is to set some context and then quickly get out of the way so that our experts can Appropriately strut their stuff. They've done done great work. So the context is in 2018 early in 2018 I asked Dr. Bob Paratini Assisted by Eric Miller to look inside of the UVM health network and to develop a mental health strategic plan. So Knowing that there's a whole world of folks in Mental health and resources that we need to work with but this was more what can we as UVM health network What should we be doing and what can we be doing to meet the needs of this? population and You know to get specific and the recommendations that came out of that were to Work on increasing the number of adult inpatient beds At Champlain Valley Physicians Hospital in Platsburg We have a child an adolescent unit. So at that time It was not well staffed and so to fully staff that and get that up to speed And I'm happy to say we were able to accomplish that and to engage in any other Partners in the broader community that we're working on increasing access for child and adolescent psychiatric or mental health needs and I believe we've done some of that and to today Integrate mental health services into primary care in a way that's more than just the window dressing of having a mental health clinician pass through a primary care office periodically All of these recommendations were driven by needs in our community you all know that Some of these things have been disrupted by the pandemic that we've been Experiencing I would say that this is all born on what the right thing to do for our Patients are to meet their needs and to meet our mission as a not-for-profit health care delivery system, but Providing these services in this degree of integration in primary care very tightly ties with our foundational Strategy to move towards value-based care in a value-based reimbursement model and a way for free for service so it serves both of our foundational strategies of meeting the needs of our patients and our communities but also to move To a business model that supports that and I think you'll hear about that in in spades so we have doctors Keegan and Olowski and Maureen Leahy who will be Providing you the information and I believe we have Jen call us who's going to provide the the slides, but Maureen am I pitching this to you or Sarah? Who's going to take over? I think I'll take it over from here. Okay, great So I'll give a brief introduction. I'm Maureen Leahy I'm the administrative director for the neurology and psychiatry departments here at EVM health network and I am the administrative lead for this project implementation and Let's dr. Pulaski introduce yourself Hi, I'm Sarah Pulaski. I'm a psychiatrist I'm a adult and child and adolescent psychiatrist and I've been in Vermont for about ten years after medical school I came here for my training and residency in my fellowship and I've worked across Many mental health settings at this point I have trained in the emergency room and then worked there as an attending inpatient services outpatients in crisis outreach So I'm very aware of all of the access challenges we have and I'm so happy to be doing this integrated work That's meant to address some of those challenges and I'll just add for a personal note I am a provider for psychiatry, but I also love someone who has been in need of services So I have a very deep kind of emotional bond to this work So I'm just always so thrilled to talk about it and happy you want to hear more. So thank you for having us all And I'm Clara Keegan. I'm a family physician I've been at the University of Vermont for 11 years now and I'm the primary care champion for the PCMHI project and I'll take it from here at this point. So the introductions actually are sort of the first Key to the success of this implementation. It's bringing together psychiatry and primary care in a room or a zoom virtual room together and understanding How to develop what is a good working relationship into a true collaboration Next slide, please So we are going to share with you today A Really to quantify a little bit Some information around the demand. I know everybody knows there's a significant demand, but we wanted to put some Some numbers and Illustrated a little bit more concretely We're going to also talk about the collaborative care model that we're working on implementing And then we'll tell you about where we're taking this hat. We are absolutely Willing and happy to answer any questions that come up along the way Or afterwards, I'm not sure of your format Next slide So this is some national information. So There's two elements going on on this slide here. So first of all, I'm going to speak to the image on the right hand side So nationally, we know that There is an unmet need for non prescribing providers So we have about 20% of the non prescribing providers nationally that we need for mental health care And the non prescribing providers are people like psychologists social workers mental health clinicians alcohol drug counselors that whole category of provider and then we know Additionally that there is a 96 percent percent unmet need for prescribers. So And again in that category, we have our physician psychiatrists. We have Nurse practitioners and PAs who are psychiatrically trained And so there's a significant void or or gap in the amount of providers that we would need to treat the population of people who have mental health problems We also know that People who Live or struggle with mental health problems Statistically don't follow through at the same rate as people who don't have mental health problems. And so Oftentimes when we start somebody in a plan of care Unless we are providing I'll say appropriate hand holding or appropriate supports They may not follow through with that plan of care Which then Can cause the outcomes to deteriorate Next slide This is sort of more painting the picture of where we are. So we know that about one in four adults and almost one in two Children have a mental health diagnosis That these numbers we pulled were from pre-pandemic. So I expect these numbers are likely higher now Given the impact the pandemic has had on on the population But even pre-pandemic these are really staggering numbers to think about serving We also sort of have brought this locally and can tell you that about 30 percent of our adult Primary care patients have a mental health diagnosis and 58 percent of our ed patients emergency department patients have a Mental health diagnosis. So what we're seeing nationally is is absolutely replicated here locally When somebody has a mental health condition We see a mean reduction in their life expectancy of about 10 years And we know that they cost the system about two and a half times as the equivalent patient without the mental health condition So to illustrate that somebody who has diabetes And depression costs the system approximately two and a half times as the person who has only diabetes and so This really speaks to the need for for clinical outcomes to address this problem. But also When we're looking at how to reduce the total cost of care of a patient or of a population Not addressing their mental health conditions has a significant financial impact And by Using the historic model that we've used where we add Outpatient psychiatrists who see a panel of you know, 100 sick patients All we're doing is causing a bottleneck to continue and it's not efficient and it's not effective Next slide So now i'm going to hand off to dr. Pulaski to tell us about the model Thank you. Um So I was asked to give a little bit of context on the history of collaborative care because now it's it's really seen as a An evidence-based model that improves outcomes and access, but it has a real historical Kind of a set of Reasons that we we kind of went in this direction And so I think in the 80s or 90s, there was a recognition that more and more people were being seen for depression particularly in primary care And there's an older statistic that about 60 percent of people with mental health Problems may be seen in primary care and not by a psychiatrist like myself So this is where we really had this seismic shift In the perception that mental health care is is delivered more wise Psychiatrists such as me that we could train people in primary care and also further support people in patients in primary care And then throughout the 2000s There was really the beginning of the research into this idea And it created this robust evidence base about 80 to now 90 randomized control trials that show the effectiveness of collaborative care amongst several aims that Maureen has already mentioned and now we're really in this era where many Healthcare systems such as ours are working on implementing these models and sustaining these models and furthering the reach of these models Next slide, please So that was kind of a broader historical overview, but these are the core components of collaborative care. And I think Um, there are really some core differences and how this compares to meeting more traditional psychiatry And um mental health care and it's really the addition of two core key members within the primary care teams One is a care manager who serves Several different functions and the other is someone like myself a psychiatric consultant And the care manager works a bit differently than maybe a classic kind of care manager. They serve the population, but they do so by using a registry which is Kind of capturing all of these different data points within primary care and looking at certain particular screening measures Utilization patterns and then trying to target interventions For people who really need them within primary care within their office versus referring them out to work with someone And then they're also trained in very particular types of psychotherapy, which um are correlated with very good outcomes such as cognitive behavioral therapy and Thinking as a psychiatrist having that offered within primary care and having that immediate access without referring out is Really crucial to the treatment of so many different conditions And then the psychiatric consultant works very differently than kind of a classic psychiatrist Their role is really on education and training of primary care providers to do this work um to fore oversight of the care manager um and to provide recommendations not always in that kind of um, You know direct patient care way, but through e-consults Through reviews of charge through case discussions and then reserving the Time in which they spend directly with a patient for some patients who are um really more Deemed appropriate to be seen by a psychiatrist and for whom that could really be beneficial for them So it's providing care very differently than a psychiatrist who may have as marine said a panel of You know a few patients whom they give You know care to and see over a course of a very long time regardless of their state of illness to trying to have well timed um Kind of well well thought out um interventions with a psychiatrist as well So it's really a different way of supporting patients in primary care Next slide, please Um, so this is an example of the continuum of care Of course this kind of model of care is part of a whole array of services And the idea is that in collaborative care models, we have There's more coordination and a focus on moving people through Our system in more of a thoughtful way And that also plays into how we've decided to do this model here. So that's the next slide, please So this is um what we are doing now, which I think this kind of slide shows Really a model of care that looks a lot like the hub and spoke model for substance use disorder care um, and I think similarly and historically the idea of substance use treatment wasn't necessarily the provision of primary care But was also within kind of specialty maybe addiction medicine treatment clinics, but the broadening of kind of the resources Has helped many more people have access and then the use of matte teams has also helped people You know remain in their medical home for a lot of this care And so what we're trying to do and what we are currently doing in our structure is having A primary care mental health integration team embedded in primary care, but having some um ability to Connect people through specialty services, which is our primary care mental health and um extension group who can provide more services um and kind of in more ongoing way and the idea is that there's some additional fluidity between these kind of services that serves overall the more people in the population than that kind of them Case load holding model. That's more traditional in psychiatry Next slide, please And then I'll pass this on to dr. Keegan So as a primary care provider We introduce the idea to our patients if we see somebody whom we think would be appropriate for Working with the behavioral health care manager We mention them as a member of our team and ask if we would be able to make that referral so that they can work together We communicate back and forth with our care manager about the patient's care and the the um Psychiatrists as well and we're able to ask them specific questions So if I have a patient who I've been treating with medication, but they're not getting better or they're having side effects or something else comes up I can get help from the psychiatrist about how to adjust those medications Without the patient needing to have an appointment with psychiatry um, we also are hoping that This will provide additional training for primary care providers to make more of us more comfortable with managing basic mental health measures We have resources for primary care providers to do the assessment like the phq 9 and the g 87 are two of the Scales that we use to measure the severity of people's Depression and anxiety and with that support from the psychiatrist. We're able to Really work at the best evidence in terms of the medications that we're that we're providing The suicide risk is something that we're working on developing as well We have some tools within our electronic health record that help us assess Suicide risk and help us develop a safety plan for patients And that's something that we're working to teach the primary care providers as well We can go to the next slide So we're hoping that by implementing this model. We're going to be seeing Specifically less depression. Hopefully less physical pain and generally seeing people do better This is what the aims model out of the university of washington has demonstrated And we're hoping that we'll be able to replicate that at university of vermont as well marine, did you have something else to say about this line? Yeah, so um When we were going through the when we were going through the process of implementing the project or the developing the implementation, I guess We did a literature search for programs and there were about eight different Mental health integration programs that we studied And they were from all across the nation and you know, we had intermountain aims and diamond and montefiore and Cherokee And when we were studying the programs the things we were looking for were Full age span implementation we were looking for models that showed both financial and clinical outcomes Um models that we felt we could replicate knowing what we know about vermont's mental health system And that would give us access to their tools um and initially We used uh, we partnered with intermountain health care in salt lake city um They however part of their package was purchasing a software tool um and We're not in a position to do it now We certainly weren't in a position when we were rolling out epic To be buying a bolt-on software tool And so we should switch gears and we went with the university of washington aims program um, it is good to note that um intermountain's implementation is Based on the aims model. So they are an aims implementation um And so when we switched to the aims model we all of a sudden got access to everything they have so We have job descriptions. We have you know, we have access to them twice a month for financial advice and operational advice We've got they have a whole website with Many of the graphics you've seen in the slide deck are from their their tool set um, and so when dr. Keyin talks about The outcomes we we hope to see or we expect to see They're based on those implementations. So we know The success that aims personally or or specifically has had and then we know the success that the people who have Implemented their programs have had and so that's really the evidence base that dr. Pulaski references and That we expect to see based on the investment that we're making And I think you go to the next slide So where we are right now. So we um, we spend a lot of time presenting this project to various levels of leadership within our network. Um, and Got feedback we involved all kinds of different roles and and um leadership and universally the idea of this implementation was accepted, I would say by everybody Nobody that we and we didn't have to pitch the idea of mental health integration to anybody What we really had to do was say here's how we're going to do it and here's what we're What we're using to show that we can um, we can do this What it's going to look like and how we can pay for it So those were really the things we focused on but universally everybody we encountered at the health network was supportive of the concept Our next steps, um, we're we're part way through implementation So we have been we have implemented in a few sites. So um, we have 38 primary care sites in the network and they range from about 10,000 patient lives or panel members Down to about a thousand. So we have some pretty small ones on the new york side of the lake And so our next steps are recruiting. So we have done we've spent the last about two years recruiting psychiatrists social workers And psychologists to help us with this implementation And we started to place them at various clinics We did deliberately start on the Vermont side of the lake because For many reasons, but primarily because when we look at The value-based population we have or the value-based payer population we have It is more heavily on the Vermont side of the lake And this is a model that financially works better with a value-based payer model And as we are so so we've got recruiting going and then we've got the hard work of culture change So we are coming into people's clinics and saying here's a psychiatrist But we want you to use them and it may be a different way than you learned to in medical school or in residency And so there's a big lift around changing the culture of care in each clinic I did put down on the list here that You know the importance of continuing the rollout and finding a non-network partner to test this with with We are able to we are a health system clearly and we are able to Invest in mental health services knowing that we see Downstream effect in reduction of ed visits reduction of inpatient admissions average length of stay I would you know, I would love to find Somebody to explore how this looks or how this works financially in a Sort of I'll say a standalone Provider of care who can't necessarily rely on the downstream effect Next slide And then this is sort of the A graphic of where we are. So we have nine practices that are currently Have people on site providing this care We have The start of a registry that we're using so our epic team is building a registry for us that will allow us to track Patient level data practice level data Provider level data and it will be what allows us to look at the program and say it's working. It's not working. We need to tweak tweak it The service options we're able to provide with this our medication management like dr. Keegan mentioned Diagnostic clarity for some of the more complicated patients that we're seeing And then panel management so that if we see triggers of things that we might think are suggestive of a mental health problem We might be able to catch those people before they escalate to a point of crisis or an ed admission And then the last sort of corner over there talks about the type of the providers of the psychiatrists and the case managers that dr Pulaski mentioned Clearly we have got if I do the math 38 minus nine, you know 29 more clinics to go plus we still have to tune these ones up a little bit but We are well underway and it's really exciting work To see When we started this and when I was looking back at the slide deck that we had The slide deck that the last presentation internally we did of this was february of 2020 And so then march hit and we all went full swing pandemic and I think I I feel one of the most Impressive things is that we've continued this work. So in the midst of the pandemic in the midst of you know, financial struggles in the midst of All kinds of curveballs. This work has continued has continued to be supported by everybody I've encountered And has retained a sense of priority when A lot of things may you know when we when we've all had to rethink what our priorities are So I think that speaks to the importance of the work Next slide So dr. Keegan dr. Pulaski and I get our 60 minutes of fame here, but there have been a ton of people involved in this work and when we look at this list of people What you see are Physicians we see social workers. We see administrators. We also have Psychiatry represented primary care Dr. Weinberger is our pediatric primary care physician It really should be probably bolded or or or some other Way to make it stand out is the primary care providers because we're really Asking them to change one more thing in the context of You know a lot of activity in their worlds and so you know our We would we would not have made it nearly this far without the support of this group And so I think that ends our formal presentation, but we're clearly here to answer whatever questions have come up for people Super thank you very much and very informative. I'll open it up for the board's questions I'll start. Um, thank you, Kevin and thank you so much for the presentation really really informative very inspiring Wow, I can't wait to see how it scales up and the impact that it has. I really appreciate I'm wondering How long do you contract with aims for is it a definite? You know kind of contract is it just to set you off to launch and then I guess a quick follow-up to that Is are there opportunities to pivot or incorporate best practices from you know other programs like intermountain? Or are you kind of a wed to this one model? um with this contract So we actually don't have a contract. This is a Friendly agreement. We show up. We ask them questions We have they have and all of their product is for public use on their websites We did bring out Dr. Anna ratsliff who is one of the architects of the aims model Out for a grand rounds presentation and had a couple of different opportunities to bounce Questions and ideas off of her, but we don't actually have a formal contract with them Um, we internally have decided this is the model We want to use theoretically if it doesn't fit vermont. We could pivot to a different Direct in a different direction Got it great, and I guess my second question is really around Lessons you've learned from the culture change, which I imagine is challenging And I'm just wondering are there lessons that you've learned here That apply to first of all, you know the the clinics that you haven't been to yet Are you you know in the implementation there? But also to other types of delivery reform efforts that might be coming down the pipeline Sounds like you've done a lot of work on culture change, and I'm wondering what some of the learnings are there um I think for me So probably one of the biggest first learnings was I was super excited still am about this thing that I'm offering And it didn't necessarily exactly match The immediate need of the primary care provider in front of them So, uh, we're talking about population health and panel management and can Controlling or treating a population of patients and the primary care provider has the patient in their office you know in some sort of Crisis or just uh despair and they they want that taken care of right now And so we we had to sort of change our approach a little bit of Setting what kind of expectations people could Expect and Trying to help them sort of see the long game of this so this so this is So that was probably the first biggest thing that I learned Um Sarah do you have any? Yeah, um, I was just thinking about um How big of a shift of care delivery this is and that's probably across the board for every provider involved in the patient as well. Um, and I can speak for the Psychiatrists where this is so different than having a set of patients whom you've seen for many many years And so the orientation around it is about now How can I be a resource in a really different and kind of creative way to a practice? And I think that's a it's uh, it's something that I I think I I didn't fully appreciate until we recruited more people into this work about Just how it's a it's a different way of being a psychiatrist and in many ways. It's a different way of Being a patient to have an e-consult versus um a direct face-to-face time with me. Um, or you know, it's a different way of being a primary care provider as well, which um I think Dr. Keegan's can speak to too. So um, I I think I appreciate more just the level of adaptation And I'm very appreciative that we have this um kind of ongoing team and so much support in doing this work Yeah, it definitely takes a different It requires a different approach to asking for help. I think a lot of us We we see people with a lot of concerns in the same visit that we're trying to manage So if I see someone for a physical and they bring a list of their concerns their knee pain and their Irregular vaginal bleeding and they're also depressed We all have different levels of what we're used to managing ourselves and what what what we want to just refer and ask for help with And the big challenge I think is that we don't have Enough psychiatrists to refer everyone with a mood disorder to psychiatry So we've needed to continually do reeducation that no, this is For our advanced practice providers and for physicians as well that this is something you can handle We're going to give you some backup and support But we need to ask you to Be the prescriber for this medication and let's show you how it's a safe thing that you can do and you can prescribe um and Maybe next time you will manage the depression and refer the knee pain But it's uh It's definitely a change to to also to to say to the patient I have a team member that I'd like to work with you Um, it's not a psychiatrist. It's a care manager and they're going to help you feel better while we're waiting for the medicine to work And then also we have to have language about i'm going to ask for help from my psychiatry colleague Who's going to review the information that I put in the note and get back to me? And then I'll let you know what they suggest rather than an actual visit with the psychiatrist which Sometimes is what patients are expecting so we need to do a lot of management of expectations And that's a work in progress Yeah, that makes a lot of sense. Thank you so much. I really appreciate this and it's inspiring work that you're all doing Okay, other questions or comments from board members But this is this is tom walsh Like jess. I just want to thank you for all that you're doing um, no real questions, but I can I want to second the The difficulty that you're talking about with culture change Um, when I was practicing clinically a long time ago now, we started using A depression and anxiety screening tool for patients who are coming to our chronic pain clinic And we expected based on the tool to have a small number of patients with a positive score All right, and it was over 10 times as high Once we started seeing and this was this is back in the late 1990s So the the need was there Unrealized need was there long back then And we we started looking at of the patients who were Testing positive on the screening tool What proportion of those patients were referred to the psychologist that we had on staff in the same hallway? We built the center with an embedded psychologist And it was less than 10 in the beginning and we're you know, we're smacking our forehead like we designed for this There's a bigger need for it than we imagined But we couldn't get the referral mechanisms and the culture that the neurosurgeons talking about psychology We couldn't get that to work it it took about three years to get the process where Over 75 of the patients with a positive screen Were seen by one of the behavioral therapist staff And two of the things that we found that were most helpful with that Patients were filling out the surveys on a computer It was scored automatically and that with those scores were provided to the clinicians at the point of care But we we had one of our computer people write a little bit of code that if the test was positive text the psychologist To then go see that patient right then just very briefly Thanks for filling this out. It helps us treat you better I want to know more about this score and how can we set up something following this visit For your back pain Right. So so we got the the clinician who could address The positive score face to face with the patient Before I as a physical therapist could screw it up or the neurosurgeon could screw it up We just got the behavioral therapist right there So that helped a lot the the other thing that we ended up doing near the end was Flipping the embedded part we think of embedding the psychologist in primary care We started to embed primary care in the psychologist's office And embed a physical therapist in the psychologist's psychology office and that also helped a lot and None of it was none of it turned out perfect. We had all kinds of difficulty getting paid and Making it work But we we never stopped because once you start doing this and you see the need for it You really can't turn your back on it after that, but it takes a long time And and so I'm really thrilled to hear what you're what you're doing and want to help Any way that I can it's it's great. It's great stuff You're you're muted still Kevin Not unusual Other questions or comments from board members Yeah, I have just one During your and thank you very much for this presentation During your presentation, you I think you said that Developing the collaborative process was Easier with entities that are are are based on value based payments And that kind of makes sense to me because there's more flexibility to be innovative rather than be You know nailed down to a bunch of procedure codes But I'm I'm wondering if there's a bias in that in that In vermont anyhow most of the commercial carriers are still on a fee for service platform and whether or not So if you could talk a little bit about The the the types of entities that you're engaging that are value based Versus engaging entities, which are fee for service based Yeah, so um We are we are Providing the same So we're not that we're the model we're providing is is the model we're providing whether you are a patient whose payer Is fee for service or is a value-based payment has a value-based payment model. Um, what we really had to do was balance um What that looked like us but what that looked like for us over our entire population and so when we looked at How we're going to pay for this The intermountain model has a article published in jama that shows that they invested $22 per member per year in this program and they saw a return of invest return on investment Of 117 dollars or 112 dollars. Excuse me. Excuse me per member per year on the program And so we took that data And we said, okay, if we only achieve half of that so we only get what was it 57 dollars and 50 cents per member per year in return um We would start to see in our population A break even uh in the expense of this model by 2024 And if we did if we did not if we did not see a positive return We just got back the 22 dollars we invested and we were able to replicate that 22 dollars Um, then we would see a a break even point around 2026. So that's so we modeled that out as our value-based um Not p&l, but our value-based model and at the same time we looked at our population and and learned that across the network again Factoring in new york We only had 47 percent of our patients in primary care on a value-based payment model Again, this was february of 2020. So that number probably has shifted a little bit And so we said in addition to Making the argument that this that this program works in a value-based payment model We need to be able to account for the other half of our business at the time that that is still fee for service And so when we looked at that information and I am looking off to my side because I have the numbers on my other screen When we looked at that information The the the argument or the logic we used was that we know That 43 percent of mental health patients are on medicaid versus 18 percent in the in the general patient population And that's inpatient outpatient replicates that 32 percent of mental health patients are on medicaid versus 14 percent for all other diagnoses. So already we have a larger portion of our population that that are on medicaid We also know that 58 percent of all ed visits at uvm mc include a mental health visit Which we had mentioned earlier and then 16 percent of ed 16 percent of the ed Census on average is carrying a mental health diagnosis. So the the number of Touches that the ed sees of mental health is is so disproportionate And one of the we have many clinical outcomes. We're we're tracking with this one of the clinical outcomes is a reduction in that ed utilization the idea is to identify patients in in a time of Pre-crisis we'll say and to be able to Reach out to them and treat them so that they do not escalate to that ed utilization which Does not bode well for a fee for service payment model. And so In answering your question we we you know, we're we're we're dealing with the payers We're dealing with and we're trusting our contracting division to start to to edge people in one way or the other But the care model we developed is the same one received by everybody and We just had to really look at the financials for both types of models that we're dealing with Okay, other comments or questions from board members I just want to say thanks for the information. It was a really interesting presentation and it's great to hear Uh About this work super. So at this point, I'm going to open it up for public comment Does any member of the public wish to offer a comment about The integration efforts by the University of Vermont health network Um, hi, my name is Sophia and I am a current student studying health care Um, and I'm just wondering if you see this model expanding to other areas of care as well Um outside of just mental health or if you think a different model would be necessary Do you mean like a I'll say a primary care neurology integration like a different specialty in place of mental health Um, I guess I mean outside of the realm of mental health Like do you see this model expanding to kind of general care so that more preventative care can be incorporated Yeah, so so I guess like how much can the role of the physician kind of increase How much can we connect different types of providers? Um, yeah, I'm just wondering if you could touch on that a bit. Yeah I'm gonna I'll touch on it and then I'm gonna hand off to dr. Keegan. So Um, I think I think there are ways we can expand and I think there are some ways we have expanded I think where the balance comes in is Um the prevalence of the problem In but in the balance of what the primary care provider can hold in their head So we are part of this program is training the primary care providers to interact with mental health conditions differently It as we start and part of the reason we're doing that is because there's such an abundance of mental health conditions in primary care If we were to replicate that with another specialty And continue to add to what we're expecting the the the generalists the primary care providers to To process we would I think we would need to be able to justify that we have I don't know if we'll have a similar but we have you know another robust volume of patients that would be treated Because the primary care doctors are primary care doctors. They're not specialists. And so, um, You know, I think conceptually it could certainly work Um, but I'll I'll that's my administrative point of view. I'll I'll hand off to dr. Keegan Thank you marion The aspect that I can think of that sort of is happening already is the e-console that dr. Pulaski mentioned So for psychiatry What that means is I asked dr. Pulaski to review the chart and then she sends me back a message in the electronic health record With her recommendations and we also have that available. It's just recently started with other specialties So one example is if we have a patient we're now recommended to screen everybody every adult for hepatitis c because The example I give is that in the 1970s. We didn't know hepatitis c existed So we didn't have the same sort of sterilization practices and people could have been exposed Through dental care or other things that so even if you don't have what you would think of as a risk factor for hepatitis c You could have acquired it without realizing so we are screening people But then if you have a positive screen, what do you do? And hepatitis c is actually something where management of that is within the scope of primary care There's a medication that can be given and so we can request an e-console from gastroenterology And similarly the patient would not see the gastroenterologist that would take months for them to get an actual appointment To see the gastroenterologist face to face But instead within one to two weeks I can get a message back From the hepatologist giving me guidance on how to manage this specific patient And that's just one example. There's multiple other specialties that we have e-consults available for I think the behavioral health care manager piece is something that's really uniquely applicable to mental health care and like morian said There's such a high proportion of patients who have a mental health Concern that that is why it makes sense to have a care manager dedicated to the mental health concerns within a practice It might make sense to have We also have a nurse care manager who helps with chronic care So that with a lot of chronic medical conditions. So that is a sort of similar pathway So my patients with diabetes and multiple other medical problems can have a nurse care manager Who's working with them as well? And that's another value-based Implementation that we have going on. So I think some of that is actually already happening. So thank you for the question Okay, next I'm going to call on ham Davis ham Thank you, Kevin. I wonder if you could ask a sort of a question and a half through you to what dr. Brumsted One of the questions here that you're in the backdrop is the need there are simply and not enough Psychiatrists available My question is and of course the backdrop here is that the there's a huge wait time problem across the board of service at uvm My question is this and it's a cheating a little bit. I know because the budgets are not due out for another Two weeks, but I first my question is Will the will the uvm budget have enough money? To make this project work And the secondary sort of question is is the constraint on is the constraint on the number of Psychiatrists or any other particular skill Is that constraint driven by difficulties in recruitment or is it driven by lack of money I think he's directing that question to you john I thought it was to you chair mullin The budget is For the uvm health network is not complete until june 30th when our board of trustees approves the budget But what's contained in that budget? Are many open Physician positions not just in psychiatry but across the board. So it's not a money issue specifically ham it's almost across the board a Recruitment issue and we're actually not doing terrible at recruitment But There's obviously a lot of need and so we have open positions for this particular program It does is boring say have incredibly High value and high stature for both the clinical And the human aspects but also from a business perspective and so This is a program that Is budgeted to succeed correct me if i'm wrong mooring, but I think again, this is a high priority stuff Stuff for us. Yes. I am everything I put in the 23 budget For this program is still there as of now And that's a little bit unique in the current environment within the uvm health network which speaks to its uh high priority Thank you, kevin Okay, is there other public comment? Is there other public comment? Hearing on like my colleagues on the board. I want to thank the team from uvm. It's uh Been fascinating learning about this integration project and uh something that Uh Definitely needed and to hear about successes is always Very encouraging. So thank you for the work that you're doing every day Thank you for having us. Yeah, thanks for the time Thank you And next i'm going to um go to the next item on the agenda Which is the accountable care organization guidance and i'm going to turn the meeting over to marissa melamed marissa Hi, thank you. Mr. Chair. Good afternoon. Can you hear me all right? We can Okay, great. I am going to Present the slides Looks like it's loading. Let me know when you can see it. So showing up. All right I'm just getting the circle still but maybe others have it already I see some nods. I'm trying a different thing for presenting. So let me have it now Can't see it. Okay Great Well, thank you again and good afternoon. Um, I'm marissa melamed Uh Associate director of health systems policy of the green mountain care board. I oversee the aco oversight process I'm joined today by my colleagues. Uh, julia bull senior Health policy analyst and michelle soyer health policy project director and we have legal support from ross mackracken And today is part two A continuation of our aco guidance presentation from Last week So the agenda for today. I'm just going to do some quick review of slides. They're really just for reference They're the same as last week. So I'm not going to spend time on the first few slides Today, we're going to focus on the documents that we're required to develop and produce For certified aco's in vermont. So this includes the certification eligibility form and the budget guidance I'll review next steps and we'll do questions and public comment So these are the slides again as a reminder that we reviewed last week There's sort of two tracks of oversight the aco budget review and the aco certification And you know, they're required to produce or we're required to produce the the documentation that we're reviewing with you today And again, this is a breakdown of how the statute works Today, we're going to be looking at the left side for aco's that plan to accept payments from Vermont one care vermont Last week we presented on the guidance for medicare only aco's And these are the standards and requirements by which we review the aco submission specifically I want to draw your attention to rule five section 5.405 Where the board may establish Benchmarks and those can be part of the review The guidance is developed based on the criteria listed in 18 bsa 93 82 as well as elements of The vermont all-pay accountable care organization model agreement between the state Of vermont and cms and a reminder that we also have the board has broad discretion to review Any issues so the guidance is is built with this criteria in mind And that the aco has the burden of justifying its budget to the board So we ask questions and provide this guidance to try to get the information that we need And if you know, it's it's on the aco to be complete in their responses Again, I reviewed this last week. So I'm not going to go over it again Just the priorities that this is that this guidance is based upon And the outcomes that we will issue the reporting manual which we've already done and these pieces of guidance by the end of the month Same I reviewed this slide last week. Some of the goals specific goals that we had set for this year Are on the right side of this slide as well as a reminder So for this section, I'm going to turn it over to michelle soyer who looks at the certification She's going to review the certification eligibility form and michelle. You can just let me know and you want me to advance Thanks you very much marissa So here is an overview of the certification process for acos As mentioned before all acos that accept payments from medicaid or commercial insurance must be certified once initially And once certified an aco must annually submit a form To the board to verify that they are continuing to meet the certification requirements And to describe any material changes to any matters addressed in the certification sections of rule five So the following this list is of the sections of rule five that cover the requirements for certification of an aco I won't take the time to read through the list, but anybody can refer back to this slide For that information Next slide please So the 2023 certification materials have undergone changes With the intention of improving the clarity and the breadth of questions While also reducing burden for both the aco and our staff The materials include a set of narrative questions and a small excel workbook that collects data Regarding the acos policies and procedures So the material changes are as follows We added word limits to each of the narrative questions in a word to in an effort to illicit answers that are direct and concise We updated and rephrased questions to improve both clarity and to focus more on updates and changes Rather than asking for overviews of operations and procedures with which we are already familiar We created a single excel workbook which combined two previous separate documents And we added four new questions to the narrative form Questions eight nine ten and fifteen were Added to address certification requirements 5.206 gik And 5.207 b These were areas that had required follow-up conversation with one care last year So we are hoping to gather that information in written form for 2023 and make sure we are covering all of the certification requirements as spelled at rule 5 We would also like to note that the staff did share drafts of these materials with both the office of the health care advocate And one care together and incorporate feedback Next slide, please The materials will be posted on our website under the 2023 aco budget and certification section and Issued to one care by july 1st along with the budget guidance And it must be completed and submitted to us on or before september 1st and from there the staff will process the submission And as a reminder, no vote is needed from the board regarding the certification materials I will hand it back to marissa to kick off the budget guidance review Great, thank you michelle So today's focus is on the certified aco budget guidance Unlike the certification form the board does need to vote to approve the updates to the guidance. We do this annually And one care vermont is currently the only certified aco in vermont. So the the only aco that is subject to this guidance So themes for the fy 23 update So each section last year we took the fy 22 guidance And each section was reviewed for the objective. What is the purpose of this section? What data and source documents? So what is sort of the primary data that we are collecting and reviewing for this section? And then what are the key narrative questions that we need or explanation to describe the data? Go, you know goals that we'd set in previous years were to make the review more data driven So we wanted to focus on what data are we collecting? What are the primary source documents and how Do they need to be explained? No, someone maybe not muted And so a highlight of updates If we could just ask whoever doesn't have their mic muted to mute it so that we can hear clearly Thank you. So the highlight of update so we added submission instructions Which I think will be really helpful in setting expectations ahead of time some of these instructions Which are spelled out in the beginning are things we tend to sort of hash out through email, but we Put them in the guidance this year things like How to you know actually do the submission how to name things how to send them to us? You know expectations around binders and such so we're just putting this in up front We updated the COVID-19 language to reflect the current environment We worked on the questions Considerably to make them more targeted Based on internal review. So in some cases you you might see less questions and some you might see more because they're more specific and this was based on internal review and then several iterations of stakeholder review With one care And the hca also took a look at this guidance ahead of time And I want to say we had a particularly collaborative process with one care this year in terms of going back and forth and and going through detailed questions and Templates and I think we've made some really good improvements through the process this year Which also includes removing areas of duplication. I'm going to talk about that a little bit more but we found that Information was being repeated in multiple places because of the way questions were asked and so we tried to identify those and Make more holistic questions that that would reduce duplication of answers Well at the same time We're also trying to reduce the amount of follow-up questions that are required after the aco submits their budget and so In addition to going through all the guidance questions We also went through the follow-up questions of which there are quite a few from last year In two rounds and tried to incorporate that information Up front into the guidance if we felt like it wasn't clear Uh, so again, I mentioned it there improved data collection and templates. You'll see we actually consolidated several templates into one um another significant Change and improvement this year is we are prepared to transition to the aco Reporting their financial information into the adaptive database the way that hospitals do This is actually a change that we've been working on for several years. It's been delayed for various reasons But this is going to improve Quite a few things year over year reporting The problem we have of passing excel documents back and forth And having sort of corrupted data or you know version control Losing historical information. Um, and so both teams I think are really excited about this There are some implications for that transition, which I'll talk about when we get to that section But um, it's an exciting improvement And then the other thing we're going to talk about is an introduction of budget and performance Targets, um, which was an expectation that was set up in last year's review So I'm going to talk about what we're recommending there So I reviewed this last week. This slide has no change from last week. The outline is still the same Um, it's just to call out that um, we sort of targeted sections one two and three a little more section five and eight are actually new sections Um, and so I'll talk about those in more detail when we get there So I'm gonna we're gonna go through oh and really oh no, this is where I pass it to you Julia Sorry, I thought I I stole your slide. Julia is going to present the next couple of sections Um, no problem. Um, can everyone hear me okay? Yeah, okay wonderful Yeah, so we will dive into the sections. We have sort of um, just as a general format the section objective and data sources and then Kind of details about what changed. Um, just because there's a lot to cover here. So um starting with section one The objective is really to provide a brief narrative that summarizes all of the components of the submission As as folks know it is a large submission. So it's helpful to kind of look at this as an overview section And so there's a lot of items listed here But um, they kind of correspond to each of the sections throughout and just getting a high level update And because this is the executive summary, there aren't any specific documents or data for this particular section And on the next slide, um, we wanted to highlight the main changes of section one Which were making revisions just to more clearly identify which information should be in the executive summary and which Which we did by editing the sub bullets of question one just to make them a little bit more clear And additionally we changed the title to the executive summary Whereas before it was called information and background Again, just to more clearly define the purpose of this section and show that it can really be very brief and high level So on the next slide section two is aco provider contracts The goal of this section is to describe the aco network Or the aco network development strategy and any changes to the provider agreements For the upcoming budget year and the data sources are the provider lists and the provider agreements And so specifically on the next slide This is second perfect. Um, the changes in this section were to really narrow the focus on To be focused on the contract itself Whereas questions that were more broad about the aco's programs in a general way were moved to a new section Section five, which marisa will be covering in a bit But specifically for question number one, we added summary tables Both or in the appendix the numbers are listed here And we updated the submission deadline to october 15th to reflect that this information comes from a federal report due to CMS on september 30th And that it always takes a little bit of time to convert that into the gmcb's format And so just giving it a more appropriate and realistic date for that For questions four and five, we added a summary table One in the narrative and one which is appendix 2.2.3 Which are both tables that one cared used in their submission last year and that we found helpful So we just wanted to put them in at the start And finally for question six, we added it to focus specifically on again the provider contracts, which is The agreement between one care and the provider and some of the elements in this question Or an older version of this question again got moved to a later section So content wasn't lost here, but this section looks a little bit shorter than it did before just because of some rearranging that we did And on the next slide section three is Similar but focused on the payer contract And the objective of this section is to describe the eco's expected or assumed payer arrangements that were used to construct the budget And assess payer agreements for qualifying as scale target initiatives And the data for this section is the eco scale target forms and payer programs Contractual agreements, which are not submitted until after they are fully executed So on the next slide, we can walk through the specific changes So the main change was again to Similar to section two to narrow it to focus really on the agreement between the payer and one care And the questions that were more broad again were moved to section five And specific changes included adding summary language to question two Or adding a summary table and then with follow-up questions only if things changed as opposed to asking for narrative about programs that In some capacity may have remained the same from last year So that's a way to help try and streamline Answers in this section And additionally we added language about scale to align with the FY 22 budget order number four Just to follow up on on that condition Questions three we talked about this recently with the revised budget presentation last month But the fixed perspective payment question was rewritten to align with the new reporting manual template for this year And finally in question four about Medicare Advantage. We added a question to Assess the status of the FY 22 budget order condition number six Which says that one care shall work with Medicare Advantage plans operating in vermont with a specific focus on vermont-based plans to develop scale target qualifying programs for FY 23 So that is it for the sections i'm covering and I will hand it back to marisa for section four Great. Thank you, julia so section four is About the total cost of care and the goal of this section is to describe the assumptions used to set Trend rates and total cost of care targets by payer program and the drivers that are affecting Settlement results of the prior year So and this is the same Section this is what section four was last year as well The data source the data that or the data and the sources that we collect for this section Are two appendices total cost of care performance by payer total aclyde and we do have historical data reported for comparison purposes And projected and budgeted trend rates by payer program So the main change here is that we were actually able to eliminate A table that we had it was settlement by hsa And it was identified through our collaboration with one care that this information could be incorporated into a template that was redesigned for section five So the information is not lost. It's just in a new consolidated template Um in question one, uh, total cost of care performance by payer total aclyde Total aclyde This is um questions in reference to appendix four point one There were some edits to clarify the instructions Question two a settlement by payer and by hsa. Um, again, this is what I just Explained um that appendix four point two or the old four point two was removed um Because settlement By by hospital is reported through financial performance presentation in november. So The aco has historically come to before the board in november or december to report um settlement results from The prior year or the most recent year that results are available And so instead of asking for this somewhat prematurely in october and then getting again when they when they present We are just referring to that presentation for settlement results Question three is In reference to the table projected and budgeted trend rates by payer program There was a question that was clarified to be consistent with benchmark trend rates for the aco attributed population and the gmcb approved rate filings I'm going to talk about this in a later slide because this is Something that the board has consistently put in their border just to be consistent across these two You know that the rate that's approved elsewhere should be consistent in this process And so that is actually a proposed target That i'm going to talk about we also clarified it because it's it's referred to in this question Um, and then the question was also updated to reflect how total cost of care targets are distributed As you know the model the risk model changed several years ago now to be HSA target setting to aco wide and and we still needed to make some updates to questions to reflect that change I'll say here too that there actually is still One care had proposed a change to the trend rates table Which we are still reviewing at the moment. We left it as is because we weren't prepared to accept that Change However, if we find that it's a recommendation we want to make We can still bring it to the board, but at the moment the table is consistent with prior years So section five is a new section The objective of this section it's called we called it the aco network program and risk arrangement policies So the idea here is as julia talked about the aco has agreements with providers and it has agreements with payers Those base agreements may not change considerably from one year to the next a lot of the Um More like specific year to year changes happen through policy the the agreements Refer to or sort of delegate Some of the decision making to the policies which are set by the one care board of managers And so that is how the program the aco programs are really developed And so we used to ask these questions like you know for your payer programs for your provider Programs we would try to ask the the questions we were asking were more sort of aco wide not based on payer or provider agreements So we narrowed the payer and provider sections Two and three the ones that julia went over and we Made this sort of more holistic section for the aco to discuss their network programs the their aco specific Network programs which much is based on policies that are set so the objective here is to describe aco program policies for provider payments And risk arrangements describe the aco risk model by payer and risk bearing entity And any aco held risk and third party risk protection So the risk management section was also incorporated into the section as well and the data and Sources here are there are two appendices Risk by payer and risk bearing entity and share saving and and loss by payer by hsa and Primary care and and risk bearing entity or hospital There's some significant work done on these tables I think there was maybe four tables that were consolidated into these two tables based on feedback That we got from one care. So that was um, I think a really helpful collaboration to make to Reduce sort of duplication of where information is presented And consolidate that information into these two tables under this section So specifically I touched on this already, but um question a lot of the questions are the same They were pulled from the provider in the payer contract sections to create this new section So it reduced sort of the duplication of asking for them twice um So question one is about provider payment strategies This was moved Question two Is about aco program goals strategies opportunities and limitations This is a new question that combines elements of past questions on risk management and provider network development Question three is about the aco risk model and it was updated. So that the updated data submission is sort of the the the source The the primary source for this question Um, though the question about the aco risk model is the same um as f y 22 Also in section five, um our questions about management of risk and financial liability um the risk model and the total cost of care accountability strategy at the hsa level Um, again, this is a question that we've had um that we put into this section As well, we ask for any additional documentation on the aco's management of financial risk that may not have been included already Section six is the aco budget for financial So the objective of this section is for the aco to submit the aco financial plan Prepared according to the full accountability or the non gap and the entity level gap financial sheets Gap is generally accepted accounting principles And this is a change that we've been working on and really implemented last year to see these two views As well, there are some customized additional financial sheets that we specify Um, for example sources and uses population health management expense breakout a hospital specific reporting leadership and management salaries and You know a main objective of the section is to describe the major variances in the financial plan from the prior year um as well as the transition to use of the adaptive database that is in That is set to to be implemented For the 2023 budget submission So the main change is the excel Templates are now in adaptive They are called sheets a 182 and a 3. Those are the standard financial sheets Information that is collected in this section again full accountability budget entity level budget variance analysis report um aco management compensation and irs form 990 Uh, and the financial audit some of these things come at slightly different time schedules in the budget submission just because of the when they are prepared, but we call them out in the guidance um because they are key piece documents um that we specified that the irs well, so the iris form 90 the one that will be turned in Next is the 2021 and then for the management compensation. We're asking for projected For the current year And a big difference that people may um think of here is that previously we published financial sheets in excel um Since they're in adaptive um the way that those reports those reports now will have to be generated by gmcv staff Into office connect for board member in public review. This is the way that it's done with the hospital budgets Is my understanding so that shouldn't be Anything new and we'll sort of avoid It'll it'll mean that the the the reports are more clear because we won't have different versions of excel floating around Other updates to the templates per section Six so there's no change to the sources and uses table The hospital participation table six point five This is actually identified as a needed improvement last year and it didn't happen. So they had to fill out the same template However, one care came to us with a proposal to update this Template for this year, which we've accepted It consolidates all the hospitals into a single template For ease of filling it out The categories by payer are revised more accurately reflect the payment structures And the risk elements were removed from this table because they're reported in a different template I mentioned the irs form 990 and the management compensation Submission and then tab 6.8 population health management expense breakout There was two improvements that were identified here one um that Bonus payments where the acl will budget the dollar amount but not the actual distribution across provider types Um, we want to be able to identify where that is So this table might show like this much money is available to be paid out But might not be exactly what is paid out. So we need to clarify that and then another improvement that was identified is that Somehow to be clear that blank cells Are they blank because there's no money allocated or because provider Types are ineligible for payments in that category. So there will be some clarification through this template But also I think in an earlier section Your providers we are Looking to clarify Which which providers are eligible for which types of payments and what what has changed if anything from prior years So we'll be able to get at that information a couple of different ways The next section is population health. I'm going to turn that over to michelle Sawyer Thanks marissa Yes, so section seven is population health The objective is to collect data and information on the aco's approach to population health management and care delivery Um, so we we receive data in the forms of five different appendices um So we have the aco clinical focus areas simply compares the status of these areas For fiscal year 2021 to the current progress in these same areas for fiscal year 2022 The high cost conditions gives us the prevalence of each of the top five highest cost conditions by payer From 2018 through 2022 Appendix 7.3 is population health and payment reform If this is something that we've collected multiple times It's just a convenient way for us to capture basic information About all of the different population health programs delivered by the aco And appendices 7.4 and 7.5 have to do with care coordination efforts 7.4 focuses on um Kind of a comparison between 2021 and 2022 given that there was a model shift between those years And uh 7.5 is new it provides us with data regarding the amounts paid out to different provider types For each program year starting in 2018 The next slide please So the main change Changes were a result of wanting to make sure that we appropriately capture information regarding one care's new care coordination model Which was implemented in 2022 And as a reminder this shifted how providers are paid for care coordination How providers report these activities and uh the sub populations of focus We also moved questions covering evaluation of any of the population health efforts to section eight Which covers all evaluation performance benchmarking So question one model of care is a question that asks for a large array of information about the model We narrowed the focus from an overview of the model to really drill down on how implementation is going The status of goal achievement and any changes made or planned for the model We added questions about how health equity shows up in their model of care as well as How and if race and ethnicity data are collected and what role they play in the model And we also asked about variations in care delivery and care coordination efforts between hsa's So for question two, um clinical focus areas we provided an updated appendices that um Compared 2021 outcomes to the current 2022 progress And focused the narrative on how quality measures are selected And and methods of evaluations that are used in this area next slide, please All right question three is around quality improvement Previously we had asked for hsa level data on four different measures We found that the usefulness of this information was limited within our purview Um So as an effort to bring up the lens from which we are viewing this data We both Eliminated three of the four measures for reporting and the fourth measure Which is the five most prevalent high cost conditions will be reported by payer program rather than hsa Um, we removed a prompt about the effects of the pandemic We assume that if the pandemic affected quality efforts that this would be noted in the narrative provided by the aco Uh question five is care coordination The most notable changes to the population health section occurred with this question Um previously there were three appendices this year. There are two and one of those is brand new as I described um The new appendix captures payments made to um different provider types for care coordination activities over time And question six is the integration of social services. Um, this question was only minorly changed We asked about whether or not the aco has evaluated the efficacy of integrating social services into their overall model And if so to share the results of those evaluations Um, I will hand this back to marissa to review section eight Thank you, michelle. Okay, there's two more sections and then the budget targets and Monitoring revised budget. So we're getting there Section eight is new It's evaluation and performance benchmarking. Um, so what we did here is we pulled all Evaluation type questions from other sections and focus them into their own section. Um, we're also including here information About the performance benchmarking system, which the board ordered in the 22 uh budget order So the objective of the section is to discuss evaluation of provider satisfaction with a co participation an aco network program And evaluation of the aco quality improvement program also discuss use of key performance indicators which was discussed during their budget hearing uh last year and Implementation of an aco performance benchmarking system and then we didn't um, we're not asking for specific data here But any relevant documents that are identified by aco by the aco that they've produced Around evaluation could be provided So this is a new section with questions pulled from across the guidance to concentrate evaluation questions in one section Questions one to five Are about provider satisfaction risk management Population health management programs quality improvement kpis These are pulled from other sections of the guidance and follow-up questions from last year um question six Is um for the the acota provide an update on the benchmarking tool implementation To assess the status of fy 22 budget order conditions number one and two This is also an area where the board may introduce performance targets where i'm going to talk about um in a in the next section We're in a future section Also in section eight On the next slide actually question six Asked about performance targets linked to national benchmarks. So the fy 22 budget order condition number two b Requires that the fy 23 budget budget guidance Introduced performance targets linked to national benchmarks along with enforcement mechanisms where one care vermont does not perform at the levels Outlined in the guidance. Um, so the order required us to to do this and include it Um, so the way that we are doing this is we're asking the acota provide progress to date on implementing the benchmarking tool and available data to establish baselines Now the green mountain care board staff, um, our team has been working really closely with um one care On implementing this condition we meet with them regularly and we've gone back and forth about, um Uh expectations and development of a report um, and they are in the middle of um contracting And we're pretty aware of where they are in um implementing this this um This requirement. Um, however, we don't have um Completed or submitted report in time for this guidance. Um, we actually Never would have expected to have it in time for this guidance So we had to kind of work around this requirement a little bit. Um, we're we're hoping to have it for the, um Budget submission we can talk about the the timing at a later date, but it's not ready in time for the guidance. Um, so the way to um To satisfy this requirement is as we are introducing this concept of setting performance targets So any targets that are set for 23 for example or future years would be determined by the green mountain care board And we are taking into consideration the implementation status of the benchmarking system These targets could include like performance targets. We're looking for um at or above the 50th percentile for example Their enforcement Like a range for when we might require a performance improvement plan and then what those performance improvement plan might require. Um, for example Discussion of best practices used by acos that are in the 90th percentile, which was um the the The ability to um, you know investigate Best practices was part of the requirement of of the tool in the board's order So we are not recommending setting any performance benchmarks Or targets for this guidance But we are uh introducing the the concept is um as provisional and will continue to um to keep you up to date on when We would have a recommendation there Section nine, um is a section that we've that we've always had. It's just a new new number since we added sections it's One of those criterias that I mentioned very very far into the beginning about Uh information needed to uh comply with a report on vermont's all-payer model agreement So the objective of this section is to describe strategies for assisting the state to achieve the goals of the vermont all-payer model agreement Describe the acos role in achieving the goals and identify opportunities for stakeholder collaboration to achieve the goal So this section is an opportunity for the aco to make clear Where they feel their role is what they feel they can affect in terms of the statewide goals and where they see addition, you know opportunities for You know collaboration with other stakeholders or where other stakeholders can You know assist them in achieving the goals The data source here, we have one appendix around all-payer model quality measures And there are no major changes to the section of the evaluation question was moved to section eight So that yeah that can conclude the reporting sections There's two other parts that are included in the guidance part two Is the aco budget targets? So the board may establish targets or benchmarks to guide the development or implementation of the aco's budget In prior years we have provided this data source the medicare united states per capita fee for service projections We provide this Each year I think it comes out in the spring as a reference for trend rate and total cost of care target setting so That table is updated for 2022 to 2023 as as trend rate and and target setting guidance, but the Way we're doing this hasn't hasn't changed. It's we've always included that table What we're adding this year to this section is that this section has always included This other targets and benchmarks So the language is the board may add other targets or benchmarks to guide the development or implementation of the aco's budget such benchmarks Set in the past have included an administrative expense ratio and a population health investment ratio among others You can see prior year budget orders for examples This year. So as I already mentioned, we're not proposing performance benchmarks for the reasons I already described But we are proposing uh to sort of introduce this topic Two budget targets that we identified could be uh set up front if you so choose In the past they've been ordered kind of on the back end at the end of the process We've said you must do these things But they could be done upfront And the reason that staff feel this would be helpful is because the aco Like any budgeting entity or the hospitals Creates their budget over the the summer and Goes through their budgeting process with their board of managers And brings to the board an approved budget that's gone through their board of managers If we can set guidance up front that that the board wants to see then they can take those They can take that guidance their board and say look our regulator has told us to meet these requirements And it could sort of streamline the process Some what and hash out some things on the front end So we have two proposals that are I Are things that we have ordered in the past that we think the the the board could Propose or or accept upfront The first one is to fund the value-based incentive fund or other pre-funded clinical quality incentive programs at a minimum Of the fy 22 revised budget amount And the second is that the fy 23 commercial benchmark trend rates Must be consistent with the aco attributed population and the gmcb approved rate filings Number two has been in the budget order as long as we've been doing budget orders. I think so I don't think it's Wildly out of line in any way and I think that the that One care probably already Does that there may be a year that I can remember that there was some discussion around this But the board could choose to set that up front that expectation up front And the first one There was some discussion around the funding of the value-based incentive fund in the prior This this past year the board did make some adjustments there. This number has fluctuated over the years and if The board Feels strongly that you'd like to set the expectation up front That it is set at at least the amounts of the current year We identified this as a possible target Um, I also want to say one thing about a a target that we're not recommending because it's had quite a bit of discussion and that's around Setting a commercial fixed perspective payment target. Um, that's been discussed by the board The reason that we're not recommending a target at this time Is is two things. So one care has publicly presented several times a goal of 23.9 percent commercial fixed perspective payments for 23 But we do know this is aspirational based on Conversations, but this is the this is the goal that they had set We're not recommending A target or accepting Or endorsing the target at this time For two reasons one. We're waiting for reporting from the aco in july Before the staff are ready to endorse their baseline and target setting methodology. So I think Julia touched on this earlier. We have updated reporting on fixed perspective payment Like targets and baseline setting that is due to us in july so we don't have that in time To say like yes, we endorse this target. Um, but the second reason is is maybe More significant in that setting a mandatory or binding fixed perspective payment percentage in the aco process That isn't binding on payers, um, which are which are parties to the relevant contracts and need to agree to any fixed perspective payment percentage Is problematic from a legal and enforcement perspective. Um, so there are some other um avenues To to to get there because I know it's of importance to the board But at this time we're not recommending it as a budget target But I did not want to ignore it as an issue Part three of the guidance is the revised budget. Um This is just updated to align with the fy 22 revised budget process Um, this process has been pretty well established. I think over the past couple Seasons we are still, um, sort of refining it to make it, you know, go smoothly Excuse me and be consistent um And those deliverables are due spring 23 Or upon execution of payer contracts. Excuse me Um Part four Is around monitoring again. We just updated this to align with the fy 22 reporting manual Which you can view at the link. Um, that's on This slide if you want to see what those reporting templates look like Um, I will say I forgot to put a slide in here Um, all of the materials are posted Of these draft materials that we're presenting are posted under today's board meeting Um, you so we tried as best we could to have the slides be an overview of all the changes But obviously the full document or the full draft Proposals on the website if people want to look at individual questions prior to next week um That is is posted A reminder of the timeline We are at June 15th. The certification form and certified ACL budget guidance presentation We've noticed a potential vote for next week if the board is ready to vote and accept on the guidance A special public comment period is open until June 20th We have received a couple of public comments on last week's presentation Medicare only so we will include kind of a A comment about the public comment that's been received Next week prior to the vote so that you Know what that is, but I believe that's been posted and board members have received that comment So that concludes our presentation. I'm going to pause another drink and um Send it back to you Mr. Chair Thank you, Marissa. I'll open it up to the board for comments or questions I'll go ahead and just jump in. I look forward to of course hearing Whatever public comment we get today and during the open period, but I like the idea of including The vbif requirement in as guidance because I think that that's a very important component to the program and I think it's it's You know last year I think we we looked at some of the proposed changes and and wanted to make sure that it remained a robust component so I think having that up front so to set the expectation is good And uh, it makes good sense that if it's something that we're putting in the budget order every year We just go ahead and put it in the guidance like the commercial Trend language So I just thought I'd chime in that those are my preliminary thoughts on those two but subject of course to hearing public comment and thinking about it for a week Thank you robin other board members Sure, I'll I'll chop it in here. Um, first of all, I want to appreciate say how much I appreciate all the hard work That's been done clearly a lot of work here, especially the attempts to streamline the guidance and Reduce duplication and clarify questions and I'm happy to hear you know moving finally towards adaptive submissions I think that is going to be really helpful And I do, uh, you know, I have to think more about it But I do appreciate and and like the proposed budget targets adding them in now a couple of Thoughts to add Section seven, I would love to see An expanded definition of of health equity consistent with the conversation we had last week with the medicare only guidance There's a reference in here to race and ethnicity data Which I think is really important I guess I would maybe you can play with the language a little bit to make it consistent with the medicare only guidance where there's a more expansive view of you know potential health disparities inclusive of sexual orientation identity disability morality other other opportunities to understand health equity So that was in section seven and then a minor adjustment proposed adjustment to consider In section five. Let me just pull up the exact question. Uh, it's section five Question six, which is discussing the aco's total cost of care accountability strategy at the hsa level In part b it says how is the aco helping hospitals and other community providers to reduce low value care and lower their total cost of care at the local hsa level I'd actually like to add In front of low value care. I'd also like to add avoidable utilization To that question and then add Second sentence to that question, which is please add specific examples and where possible Quantify the aco's direct impact on Reducing avoidable utilization low value care and lowering total cost of care at the hsa level And I guess you know what I'm trying to get at there is I want to hear I don't want to just hear about how they're doing it I want to hear about the impact of the the work that they're doing And so I want to you know specific examples where we can see a direct impact of that work And to the degree that they can quantify identify, you know cost savings from their From their efforts or reductions in low value care or reductions in avoidable utilization things like that, so I'm happy to send language to you Marisa later if you know, but hopefully if that makes sense what I've just described I'd like to see a little more depth in those questions But other than that, I just want to say I really appreciate again all the hard work here I think we're making progress every year and improving our guidance Okay, other questions or comments from the board Yeah, my comment is on part two and the not including the Some specifics as a pertains to a budget target for commercial I think that's a fatal flaw in this in my opinion that For five years down the road in health care with the Alpera model And we have less than one and a half to two percent of Commercial payments in the form of fixed perspective payments Clearly understanding that there are some definite definitional issues here But even back in Mike Smith's implementation improvement plan a couple of years ago It was emphasized that this is an arena that needs some work and I do think it's time for an intervention in this area That we have You know the largest payer in the state um And they are they are fusive in their praise for health care reform and value-based payments Yet when the rubber hit the road that they don't show up and uh, and I sometimes wonder I look at the rate increases that The commercials are requesting for 2023 And we just wonder what those might be if we'd have fixed perspective payments in that arena two years ago So, um, I I'm not I'm not prone to Avoid that issue because we don't have enough data Or there are a couple of reasons um The reasons that you mentioned I just think that We're far down the road here. There's a lot of water Under the bridge. We should be farther down the road. I mean and when you have positive reports like the nor norak report on savings in medicare and you have diva happy with the implementation of of their Unreconciled fixed perspective payments. I just think uh And and you have the heads corporate heads of at least one of them And I've read it before I won't read it again praising value-based Um payments and we just kicked the can down the road and uh, that's not a place I want to be in but You know, there's a lot of great work in this a presentation a lot of simplification and clarity But that to me is a foundational flaw That we as a regulator are not After four or five years of health care reform. We are not putting the heat on the carriers um, and and urging um, one care which has an intermediary position between Payers and providers asking them at least to to uh push this ball down the court They can't make it happen But but they can be aggressive and and we can ask them to come back to us and tell us Why why they have been successful if they are successful in engaging the commercials or to tell us why they What are the barriers that? You know that inhibit this engagement, but I I just I I I think You know more kind of process and reporting and things of that sort Um, and then you look at the 12 and 16 rate increases that are being You know asked, um, not that fixed prospective payments would solve all of that But um that that is a piece of the puzzle that we've said all along is fundamental toward affordability, which is fixed perspective payments and we have Basically mouse meat um in that regard when it comes about you know to the to the commercial carriers But we'll we'll talk about this more in the two by two Yes, and I can respond to that too now if that's okay. I um, I I hear you and I agree with you and I wanted to do this for you um and and for the for the project, but um I found that um if we can't um One we're going to we are continuing to ask them the questions that you raise and get the reporting So that's not going to go away. Um, and and put pressure on through the through the um through the process Um the you know and talk about what limited what the limitations are and the barriers and and such So we can still continue to do all that What I didn't feel that we could do is set a target that we can't that we really have no way of um of enforcing I mean that target that one care has proposed is still out there. We still know what it is We still know it's not being met. So I think the pressure is still there Um, it just didn't feel like um, it was something that we were comfortable sort of Setting a target that can't really have any teeth. So that's the that's the difference I'm not letting up on asking these questions and having those conversations um as part of the process If that helps at all, but yes, we can certainly talk about it more before next week But I I know and we don't believe with us much more now, but I I know that There are differences in the ftp's uh, uh that that um, we engage with medicare and those that we engage with Medicaid But somewhere between zero percent essentially And the 23.9 percent there is a there is a marker that the Private carriers can achieve especially given their publicly expressed um of usiveness about healthcare reform and value-based payments. Um, and We've had we're in our fifth year of the all-payer model and we're we're literally down Uh, according to the aco's documents, you know, to less than a hundred thousand dollars in fixed perspective payments Aligned with the private carriers and that that just to me is unacceptable Okay, is there other board comments or questions? Hearing none, I'll open it up for public comment Does any member of the public wish to offer comments on the aco budget guidance? And I'll go first to walter carpenter Thanks, kevin I just Tom pelham took most of my questions, which is a good thing. So I'll let tom stand my only other Comment here Along with what tom pelham said is why does everything have to be so complicated about american health care I've been listening to this for hours for a whole presentation and I don't think a nasa engineer could understand half of it Okay, thank you walter. Is there other public comment? Is there other public comment? Hearing and seeing none. I want to thank marissa and michelle and julia for the presentation today And marissa if you could just remind us of the timeline Yes, so we've set a potential vote for next week We'd like to receive any written comments by the 20th so that we Have a quick turnaround to incorporate that The board's ready to vote next week. We can do so there sounds like there's a few Minor changes or anything else we identify. We will let you know what that is prior to the vote Oh, and then that needs to be issued to The aco's By july One so we then prepare the documents if they need to be prepared in any way and post them by the end of the month So we'll do it earlier if they're ready to go Okay, great. Thank you so much So we're gonna change gears now and we're going to have an overview of the 2022 legislative session and i'm gonna turn the meeting over to christina mcgloughlin christina Thank you chair mcgloughlin Good afternoon everyone. Uh, we as kevin said are switching to i can barely hear you christina Oh, okay. I'll speak up. Is that better? Yes much. Okay. All right. I'm in the office So i'm trying not to be too loud for other folks Uh, so as uh chair mcgloughlin said we are switching over to the 2022 legislative session. This is just a brief presentation of the bills uh that were um Move through the session and actually enacted all of them That we were tracking relating to our health care system And the green mount care board, uh, directly as well um, so i'm just going to share my screen and i'll Ask soon to See if you can actually see it on your screen Let me know if that's popped up because now i can't see all of you So it looks like it's trying Okay, i'll give it another minute Can anybody else see it? I see just nodding So i must be the last one to be getting the power points lately, but I still have the the cm circle, but that's okay. Go ahead. Okay. Uh, like I said, I know it was a packed agenda So I kept this very brief So starting on the uh first slide slide number two um We are looking at the list of bills house incident bills that i'll be reviewing I definitely focused on the highlights here I wanted to keep the short and concise uh for everyone And at the end of the slide deck, you'll see a link to the general assembly website So if you want more information on these bills, um to read the full bills or the act summaries Um, they're they are available on the website. Um, but I wanted to hit the highlights here Um, it's focusing like I said on the health care system and the green mount care boards work I did not, uh, add the budget language or anything from the big budget bill act 185. Um We could have gone a whole rabbit hole down there, but that did include health care workforce Appropriations for the health care workforce and other health care related items. So I just wanted to flag that So moving to slide three This is act 85 and act extending coven 19 flexibilities this, uh, act Extended certain coven 19 related health care, uh, regulatory flexibility provisions through march 31st of next year These flexibilities were first enacted in act 91 of 2020 and then were extended previously in act 140 of 2020 In act six of 2021 Uh, we wanted to flag this since it does include the board's regulatory processes in this bill It also directs the board to consider the hospitalers labor costs and investments as well as the impacts of these costs on and investments on the affordability of health care This relates to any hospital budget proceeding conducted on or after february 1st of this year To establish or enforce a hospital for 22 or 23 budget It also created a registration process To allow out of state health care professionals to deliver care to patients in vermont using telehealth From april of this year through june 30th of next year So moving on to slide four This is act 108 an act relating to coverage for hearing aids Just some background here The purpose of the bill Is outlined in the beginning of this act And the general assembly noted that they recognize the negative health outcomes associated with untreated hearing loss And also notes the intention to support access to hearing aids and related services And ensure continued coverage of hearing aids and services in vermont This bill also notes that the board approved this past march the recommendation from the department of vermont health access Also known as diva to add coverage to vermont's essential health benefit benchmark plan For one hearing aid per year every three years and an annual exam starting 2024 So going into the expanding coverage of hearing aids This directs diva and dfr department of financial regulation to provide an update on To the health reform oversight committee also known as hrock regarding the state's application to the federal agencies to modify the essential health benefit Essential health benefits in the benchmark plan on or before november 1st of this year It also ensures medicaid Continues coverage for medically necessary hearing aids and audiology services And outlines the coverage requirement for hearing aids and related services for large group plans Which will take effect january 1 of 2024 So moving to slide five We are now on act 107 an act relating to telehealth licensure A licensure registration system This creates a licensure registration system for telehealth This allows a healthcare professional who is not otherwise licensed certified Or registered in vermont but is in good standing in any other us jurisdiction To obtain a telehealth license or registration to provide services to a patient located in vermont using telehealth These licenses would be administered By the office of professional regulation or the board of medical practice And outlines the number of patients a healthcare professional is allowed to deliver care to during the license terms The bill also notes healthcare professionals Continue to have the option to pursue a full license to practice If they wish to do so Moving to slide Six we are now on act 119 patient financial policies and medical debt protection This creates a really directs large healthcare facilities to develop a written financial assistance policy that At a minimum complies with the provisions outlined in this act in any applicable federal requirements The policy has to apply to all emergency and other medically necessary services That the large facility offers and provide discounted care to vermont residents And to individuals who live in vermont at the time services are delivered But may lack stable permanent housing Qualifications for free or discounted care are based on household income at or below a percentage of fpl The bill clearly outlines those percentages And then moving on to implementation of this The facility has to take steps before seeking payment So before Asking for payment they Have to determine whether the the patient has health insurance or other coverage And also provide patients with information on how to apply for public programs if uninsured And how to apply for health insurance and private programs On to slide seven continuing with this with act 119 There's a section on public education and information The healthcare facilities have to publicize financial Assistance policies widely So that folks are aware of these policies There's also with enforcement The office of the attorney general in vermont has the authority to make rules Conduct civil investigations and turn to assurances of discontinuance and bring civil actions for any violations And then The bill includes a few other things including that the hospitals The facilities have to submit a plain language summary of its financial assistance policy to the board During the hospital fyi 25 budget review process It also doesn't allow the facilities to sell medical debt And all facilities must comply no later than july 1st of 2024 Moving on to act 131, which is an act relating to pharmacy benefit management This bill was very comprehensive and I definitely hit the highlights here So I recommend taking a look at the bill further if you're interested And getting more into the details But section one Actually outlined the intent to increase access to needed medications By making prescription drugs more affordable and accessible by increasing state regulation of pvms and Sorry a pharmacy benefit managers and pharmacy benefit management Uh, so the bill Drax the department of financial regulation to monitor the cost impacts of pbm regulation And recommended changes as needed to promote health care affordability And also consider issues including pbm license shares spread to pricing pharmacists dispensing fees And with the board of pharmacy issues regarding pharmacist scope of practice A dfr then has to report these findings and recommendations By january 15th of 2023 So as you could imagine this bill prohibits pbms from doing quite a few things Including restricting the information pharmacies and pharmacists can provide to the department of financial regulation law enforcement or state or federal government officials It also prohibits discriminating against 340 b covered entities and extends an existing Prohibition on pbms imposing certain requirements on pharmacies related to 340 b drugs Uh prohibits reimbursing pharmacies and pharmacists in vermont less Then they would reimburse pbm affiliate affiliates for the same services and required Privates from requiring covered persons to use mail order pharmacies or pbm affiliates Or from increasing out-of-pocket cost when a covered person does not use mail order pharmacy or a pbm affiliate Continuing with act 131 It also expands prohibitions on gag clauses and pbm contracts with pharmacies and pharmacists It provides additional rights to pharmacies during a pbm audit And there's a section on white and brown bagging Prohibits health insurers and pbms from requiring that a pharmacy dispense a medication directly to a patient for The patient to bring to the provider's office to be administered there, which is brown bagging Or that a pharmacy dispense medication directly to a provider's office to be administered to the patient in the provider's office Also known as white bagging Moving on to slide 10. We're now on act 137 Which is an act relating to miscellaneous provisions affecting health insurance regulation This is a much larger bill, but we're hitting the highlights that relate to this presentation So includes language on the no surprises act It requires health insurance insurers and health care providers To go apply with the requirements of the federal no surprises act And directs dfr to enforce those requirements and collaborate with other stakeholders to inform the providers of their responsibilities under the federal act dfr is allowed to refer cases of non-compliance to the federal government or to the office of the vermont attorney general There's also language relating to the individual small group markets. It unmerged Or continue to keep the markets unmerged for plan year 2023 And also dfr and consultation with the board is to convene a working group to look at into maintaining separate Also known as unmerged markets in a manner that reduces premiums in the small group market without increasing costs in the individual market These findings and recommendations are due to the legislature on or before january 15th of 2023 Moving on to slide 11 We are now on uh Now moving on to the senate bills. So act 183 was an act relating to economic and workforce development As you can imagine this uh provided a lot of appropriations to uh support workforce and economic development Including healthcare workforce You'll notice many of the healthcare workforce sections are focused on nursing And starting with the first one here emergency grants to nurse educators Two million was appropriated to the department of health to provide emergency interim grants to vermont nursing schools Over three years with equal amounts distributed in the fiscal years 2023 2024 and 2025 There's also funds appropriated to nurse preceptor grants and there's a report $400,000 uh appropriated from the general fund to a hs and f y 23 to provide incentive grants to hospital employed nurses In vermont to serve as preceptors for students enrolled in vermont nursing school programs It also uh directs the director of health care reform to convene a working group to identify ways to increase placement opportunities and provide A report based on those findings There's also funds uh 2.5 million Uh to the vermont student assistance corporation also known as visac and f y 23 to provide grants To health care employers to establish or expand partnerships with vermont nursing schools to create nursing pipeline or apprenticeship programs Taking with act 183 we're now on slide 12 Uh There are funds appropriated to the department of health to establish a vermont nursing forgivable loan program Which provides scholarships for nursing students Recipients agree to work as a nurse in vermont for a minimum of one year Uh, there's also a nursing physician assistant loan repayment 2.5 million in general fund dollars to the department of health to establish an administer a loan repayment program for nurses and physician assistants in coordination with visac And there's a nurse faculty forgivable loan program Half million dollars uh to the department of health to create and administer a program to offer forgivable loans to nurse faculty members At a vermont nursing school And for each year of service at a nursing school in vermont an eligible Individual receives a full academic year of forgivable loan benefit sticking with act 283 again There is a nurse faculty loan repayment program This is funds appropriated to the department of health to provide loan repayment on behalf of eligible nurse faculty members The amount recipients can receive is equal to the value of one academic year of loans for every year of service As a member of the nurse faculty at a nursing school in vermont There's also 1.5 million to the department of health to provide forgivable loans to eligible mental health professionals This is available to students enrolled in a master's program at an eligible school who commit to working as mental health professional in vermont And 1.25 million To a hs uh to be distributed to the designated specialized services agencies For loan repayment and tuition assistance for recruitment and retention of high quality mental health And substance use disorder treatment professionals 514 now Keeping with act 283. There's also a language relating to the board's hospital budget review So the board is directed to To review hospital investments and workforce development initiatives Including nursing workforce pipeline collaborations with nursing schools and compensation and other support for nurse preceptors Also, uh asked to consider the salaries for the hospital's executive and clinical leadership And the hospital's salary spread including a comparison of median salaries to the medians of north or new england states and uh The board may exclude all or a portion of a hospital's investments in nursing workforce development initiatives From an otherwise applicable financial limitation to the hospital's budget or budget growth Then finally, there is um There are funds for a healthcare workforce data center Uh, there's uh 750 000 dollars appropriated to a hs to establish and operate a statewide healthcare workforce data center This includes a position in a hs, um the healthcare workforce data center manager Uh to manage the healthcare workforce data center created And then there's another position created the healthcare workforce coordinator There are funds appropriated For one classified three-year position in a hs also known as the healthcare workforce coordinator This coordinator is specifically focused on building Educational clinical and housing partnerships and support structures to increase improved healthcare workforce training recruitment and retention in the state of vermont So last but not least we are on act 167 Which is an act relating to healthcare reform initiatives data collection and access to home and community based services This bill includes language On the subsequent 8 p.m. Agreement all-payer model agreement This directs the director of healthcare reform in collaboration with the board to develop a proposal for a subsequent agreement with the center for medicare and medicaid innovation They must include the consideration of alternative payment and delivery system approaches For hospital services and community-based providers such as primary care Providers mental health providers substance use disorder treatment providers skilled nursing facilities home health agencies and providers of long-term care services and supports The process for developing the proposal includes Opportunities for meaningful participation by the full continuum of health care and social service providers Payers participants in the health care system and other interested stakeholders Certainly a long list of folks involved And then the board is to collaborate with aHS and stakeholders to build on successful health care delivery system reform efforts By developing value-based payments including global payments from all payers to vermont hospitals or acos or both There are a couple reporting requirements related to this Honor before january 15th of 2023 the director of health care reform and the board is to report on their activities And honor before march 15th of 2023 the director of health care reform is to provide an update Regarding the agency stakeholder engagement process to the legislature Now on slide 17 continuing with act 167 There's a section focused on a hospital system transformation and stakeholder engagement So the board in collaboration with the director of health care reform over at aHS Is to develop and conduct a data informed patient focused community inclusive engagement process for vermont's hospitals To reduce inefficient inefficiencies lower cost and improve population health outcomes outcomes Reduce health inequities and increase access to essential services while maintaining sufficient capacity for emergency management The out it outlines the requirements for the engagement process Including that it is conducted by the director of health care reform And then honor before january 15th of next year the board is to provide an update on the community engagement piece And then on slide 18 Keeping with act 167 There's a section on the hie health information exchange steering committee The committee is to include a data integration strategy and the hie strategic plan to merge claims and clinical data There's also a section relating to the health care database Existing law limited the ability to analyze clinical data and claims together resulting in Potentially duplicative data collection and limited the use for delivery system reform So the change in this bill allows the board to bring data together at a patient level There's also a section directing the board to summarize key findings and recommendations from reports by and for the board And then lastly Without keeping with act 167 There is a section on prior authorization It directs dfr to explore the feasibility of requiring insurers and their prior off vendors to access clinical data from the vermont health information exchange Whenever possible to support prior off requests and situations of which a request can't be automatically approved And then dfr is to uh create a report uh first dfr is to direct health insurance to provide prior off information in a certain format to Enable the department to analyze opportunities to align and streamline prior off request processes And then share its findings and recommendations with the board And then the board and uh dfr is to uh collaborate to provide recommendations To the legislature under before jader 15th of 2023 regarding the statutory changes necessary To align and streamline prior off processes and requirements across health insurers Uh act 167 also includes sections related to the blueprint for health options for extending moderate need supports and Medicaid reimbursement We're now on to the question slide So i'll turn it over to uh chair mullen Thank you christian Very informative. We'll start with the board members questions or comments have um A question, but I did have a comment christine I think there's a correction needed on slide 17 um Because that the engagement that's led by the director of health care firm is the all pair model engagement So we should make sure that that's a little clearer there. Thank you. There's two different engagements in that bill. So yes Yes, there's a lot of engagement. Yes. I'll make that update and uh repost. Thank you Okay, any questions for christina or comments from the board? Good job summarizing a lot of information there christina For everyone's sake Chair mullen, can I just thank christina for following all of this legislation throughout the session? Of course, we know it's your job, but you did a really great job in following so much. I know there's a lot of people on this line who were Uh busy as well following all of the legislation and informing us. So thank you very much Thank you Okay, we're going to open it up for public comment. Does any member of the public wish to offer comment? It's the benefit of going last christina Everyone's tired They want to get outside Nice job christina Thank you alter Okay, well, thank you very much and is there any old business to come before the board? Is there any new business to come before the board? Is there a motion to adjourn? So moved Second It's been moved and seconded to adjourn all those in favor. Please signify by saying aye Aye. Any opposed please signify by saying nay Thank you everyone and have a great rest of the day