 Good afternoon and welcome to the Green Mountain Care Board on this historic day. This is actually the first official board meeting of 2021. And the first item on the agenda will be the Executive Director's Report, Susan Barrett. And just because it's 2021, I have to start the meeting out by saying, I'm on mute. Just also to agree with you, it's been a while since we've all met a couple of weeks and our world is very different today. And I just want to mark today by, you know, in so many ways, having Kamala Harris as the first female Black and of Asian descent vice president. I know it means a lot to a lot of people and it's pretty exciting for me. So, but back to the board business, we have a few meetings coming up that I just wanted to make sure folks were aware of. Today, we're going to hear from our data team and our hospital folks on the federal price transparency update. And then tonight, we have a meeting with our primary care advisory group that starts at five. And then next Monday, we continue to have meetings with our prescription drug technical advisory group. I want to thank board member Lunge and Christina Gloffland for leading those. And of course, all the stakeholders participating in those. And then next week, we're going to hear an update from our data team. So that's going to start in the morning. We have a full day of meetings and starting at 10 a.m. And then in the afternoon, we'll have an all pair of model update on some reports, and we'll have the all pair of model differential reports. And that is all I have to report, Mr. Chair. Happy 2021. Did you want to mention a few reports that are now available on the website? I think that's a great idea. So we did submit our annual report to the legislature, our statute, and that is on our website. And there are some also other all pair of model reports on our website. And I may be forgetting something that you're referring to, chair Mullen, but that was the big one, the annual report. Okay. Thank you, Susan. The next item on the agenda are the minutes of Wednesday, December 30th. Who would like to put 2020 behind us? So moved. Second. It's been moved and seconded to accept the minutes of Wednesday, December 30th, without any additions, deletions, or corrections. Is there any discussion? You're hearing none. All those in favor signify by saying aye. Aye. Those opposed, signify by saying nay. Motion carries unanimously. And now we're going to move over to the subject of today's meeting. And as Susan said, this meeting has been somewhat split up because of all the circumstances of today. We've focused strictly this afternoon on federal price transparency and we'll have the rest of the data team updates next week. But at this time, I'm going to turn it over to Sarah Lindberg for a discussion on the new rule that went into effect January 1st regarding price transparency from our hospital. So Sarah. Good afternoon. This is Sarah Lindberg from the Green Mountain Care Board. I had our data team and I will start by asking if everyone can see the slides that I'm presenting. We can. All right, that's a good start. So I'm here to offer a pretty cursory update on the federal price transparency rule. A lot of information was dropped and so we're still digesting it. And I've been working with both our legal and hospital finance teams as we tried to do that. So as a review, this is a federal requirement for hospitals according to a CMS rule that said as of January 1st of this year, they would have to post two new resources publicly. One is a machine readable file of all the standard charges for their items and services and then a subset of those services that are dictated by CMS in a consumer friendly list. And they refer to these as shoppable services. It will apply to all of Vermont's general hospitals, those for which you do the hospital budget review. But it does not apply to facilities other than hospitals, even if they might perform similar services. The requirement is limited to those rates negotiated with commercial insurers. So there's nothing that would prevent a hospital from including it with other information from their public payers and they could integrate that. But the rule does not require that. As I said, we're actively reviewing the information that has been posted by the hospital so far. Right off the bat, we notice a lot of... Is that like a Casio swatch from the 80s? This is a great sound. So it's right off the bat that I look like there was a great deal of variability particularly in the way that they approach the shoppable services and that was allowed in the rule. So some people posted spreadsheets or comma delimited files. Other people used price estimator tools and other hospitals went with the interactive web form approach. So you pick a service, you pick a type of insurance, you pick a policy number and it will show you the information related to that shoppable service. So here's an example of a price estimator tool on the Dartmouth Hitchcock website. So you look for a keyword or CPT code or you can browse by kind of categories of service and then it prompts you for information about your insurance and then you would see a range of negotiated rates including the one for your particular information you provided. That's an important caveat. And then another example, Rutland has a series of downloadable files. So there's the patient-friendly pricing file, the full scope of their services and then that machine readable charge master which has been required for a longer period of time. So a few important notes that this rule is consumer focused. So the real audience intended was for consumers to get some information about expected expenses for their specific health care services at a hospital. But what it doesn't do is like talk about the cost sharing or the expected patient share of that expense. This is the full negotiated amount. So that's one thing that limits its usefulness if a consumer is trying to figure out exactly what they would be on the hook for. And given the variety of different formats and organizations and approaches to the information, I think that this highlights how complex this area is and that there's just a lot of variation in billing practices among our hospitals. An important thing for anyone seeking services is that the care that you think you're going for might not be what you ultimately get. One classic example is you think you're going for a colonoscopy to screen and they end up removing five polyps. So what you are expecting to spend is going to be a lot different than what the actual care that you needed was. And so that's just we want to make sure that whatever we do with this information we're very responsible and don't make any false promises because some of this is very difficult to predict ahead of time. And to that end, there may be programs or other need-based services that a patient might be eligible for that if they were to reach out and contact the hospital ahead of time, they may be able to get set up and avoid some of these insurance-based reimbursements and that might end up being more beneficial to the consumer's pocketbook. And so I think there's going to be a lot of stress in that it's always a good idea to contact a hospital proactively to talk about what might be on the table before seeking service. And as I already mentioned that these are the full negotiated amounts or allowed amounts and is not reflecting the patient's expected share. So without that kind of insurer side of the equation, that's very difficult if not impossible for a hospital to necessarily understand ahead of time again. So in thinking through the regulatory applications, again, I can't emphasize enough that this is just an incredibly complex set of information. So we're still reviewing and assessing the scope of what we're going to want to do. But as I alluded to earlier, there's some things that are going to make apples-apples comparisons challenging. So the guidance provided by CMS did allow some room for interpretation. So that is something that we would definitely want to make sure that we were careful in investigating before we tried to use it in any public-facing or regulatory context. Again, that variability and billing practices is something that can be hard to iron out even if you have kind of a code-level negotiated rate. The limitation to commercial rates, so the reason that's important to think about is there can be a relationship between hospitals reimbursements in other public programs and how that flows to their commercial negotiated rates. So I think that it would be as a regulator that it would be pretty important to consider the full breadth of the patients at a hospital seeing and try to incorporate that. And there's one major area in how the rule directed hospitals to account for non-employed physicians. That might be a real a real significant issue to consider if we're going to try to do any comparisons across hospitals, particularly tertiary care hospitals and the way they might handle admitting rights for non-employed physicians. So that's just some examples of the things that we're thinking through at our first blush. And I can't say enough that all of this is really based on a fee-for-service mindset and isn't really looking at it from the value-based approach that things like the all-payor model are intended to look at where maybe per-service prices is less of a consideration. Some other things to keep in mind. I asked a staff member Jeffrey to do literature search. Thank you very much, Jeff. And I did this years ago and I think there's a lot of fear that this might actually increase prices by adding some negotiating power for maybe hospitals and making that negotiation unbalanced. We didn't see evidence of that in the literature, but there is not a lot of research in this area, particularly for samples of any significant size. So this is going to be a very interesting experiment. But to date, you know, we found that very few consumers seem to adopt these tools, you know, ranging from two and a half to five percent. And because the negotiated rate is not closely associated with the consumer's expected share, there really isn't a lot of incentive to use them. With the counter example being those with high deductible health plans where, you know, maybe they do have more skin in the game and are more motivated to do this kind of shopping. We also know that, as I alluded to earlier, sometimes because of the way your benefits are structured, shopping is less of possibility, particularly if there's a, you know, HMO or some sort of limitation on your network. You might be limited in what you are able to access. And yeah, but we do think that according to the literature that these kind of actual negotiated rates or should say allowed amounts will probably be more likely to spur any changes if they're there than the charge master, which we know is not necessarily very closely associated with what the hospitals actually get reimbursed. And just, you know, down the pike, there is a related requirement that was adopted for most health plans and issuers to post machine readable files for their in network, out of network and prescription drug rates, which would apply for plan year 2022 onward. That's still early days and much like this requirement, I would not be surprised if there were some legal action taken in that area. So we'll certainly be keeping our eyes out for anything that develops on that front as well. So in the meantime, we will be working on gathering and synthesizing this complex data set. And this will be one of the things that in our enhanced data validation workgroup, we will be considering for its utility in trying to validate actual reimbursements that we see in our all claims payer database of vCures. So we're going to kind of try to kick the tires on this with providers directly as part of that process and figure out, you know, what information can be, this can be used for and how to do that in a responsible way and how that might differ depending on if the audience so how we might package it for a consumer, for instance, might be different than say a board member or yeah. And you know, I think the main thing is just really it's going to make sure we understand this fully so that we're using it appropriately. But I do think it's a, you know, it's a new data point. It's never happened before, so it's hard to predict exactly how it's going to go. But we are going to be following it and keeping you posted. So those are the slides I have today. Any questions I can address? Thank you, Sarah. That's very, very helpful. I'll start out with a couple. I do agree with you that I think that for the most part, price tools have not been effective. And it all gets back to the fact that what the patient looks at is what they would be paying. And in that, that's therein lies the real problem with healthcare, because you never get a true price equilibrium with supply and demand, because if someone else is paying the majority of the expense, all you really care about is convenience and quality. And so you end up usually going to your hometown providers. But I do think that we've seen tremendously poor uptake from the actual tools that, for example, Blue Cross Blue Shield has a tool for any of their members to access. And it just doesn't result in a lot of healthcare migration. But on the flip side of that, on the shoppable services line anyways, basically what the federal government did was 75 of the ones that they picked. And then the hospital had some leeway on the other 225, plus they had the ability to do the calculator instead of the shoppable services. But what I see there is there are a couple of scenarios where it could be quite useful and quite utilized. So for example, you mentioned a high deductible plan. It fits, say for example, the beginning of December. And all of a sudden you need to have something done. It probably doesn't matter anything other than trying to get the best price that you can get for that. And I think in that situation, if somebody all of a sudden needed to have a medical procedure done, they would be looking for the lowest price alternative. And the other situation that I point to is where employers could become major players in this if they created a system where the employee had some benefit. So say for example, your local hospital charges $1,000 more than one that's 45 minutes away for a procedure. Let's pick something, a colonoscopy. If the employer gave the employee a few hundred dollars as an incentive to go to the lowest cost alternative, they would still see a huge savings themselves in their self-insured plans. So I think that there is some usefulness. It's not going to be what everybody had hoped for. But do you see those types of utilitarian uses as well? Yeah, I think those are all totally valid use cases. And yeah, to your point, I think if there's a way we could say, even if you're not paying for it at the time of service in a deductible or a copay, that there's a reason premiums keep increasing. So trying to remind people that even if it's a little down the line that it does have an impact on their health insurance. And I think we've heard a lot through our work with the all-payer claims database that providing more meaningful tools for purchasers, such as employers, is really an important thing to focus on. And we're happy to help provide any information that might help in that domain. So on the larger posting that's supposed to be in a machine-readable format of all the services provided by a hospital, what is the definition of machine-readable? And is there an easy way to input that data from their website to some type of a program that would create a comparison tool? I know that as a board member, one of the more frustrating things is that a 4% increase from one hospital as compared to a 3% increase, it doesn't necessarily mean that that 4% increase makes them more expensive than the hospital that's only asking for the 3% increase. So is that something that is easily extrapolated from and put into some type of usable format? So I would say that machine-readable had a few... So it just means kind of like it's something you could put into some sort of program to read. So they specify a few different formats in which you can do that. However, there wasn't a consistent layout, which means that some of these files might have 300 rows or columns across, some maybe have 150 and there's not necessarily consistency. There's certain columns we know need to be there for every hospital, like the minimum and maximum for instance. But aside from that, there's just a lot of variation. And so figuring out a way to clean it up and make it as apples to apples as possible is not trivial and something that we'll be certainly working on and figuring out the best way to do that. And then of course, because hospitals offer different services, it might actually require a little clinical insight in where comparisons are appropriate and where they might not be. With just the 14 hospitals, would we be able to selectively go to each one and call out the fields and then put it into a comparable field? On our own database? Yeah, and I haven't spent enough time with every hospital file to answer that today, but that's the type of thing that we're exploring to figure and validating. I think that validation will be an important step. Super. Thank you, Sarah. Questions from the board? I have one. Well, I'm just, as this moves forward, it could get pretty complicated because this is kind of public data that's out there broadly in the public on a hospital basis, and it has the CMS label on it, which gives it some high credibility, I think. And I just wonder for the board, as we go forward, how we position ourselves to use the data for our work, but also to maybe be a referee on how the data can be used or misused. And I think Sarah's presentation clearly reflects that concern and complexity that it's a lot of data. I took a, I'm going to make Sarah nervous here a little bit. So, Sarah, I will admit from the beginning of this comment, this is not an analysis, but I took a look at the UVM Medical Centers and they had, it's a big spreadsheet, an Excel spreadsheet, and they have 14,237 rows of procedure codes. And of those, 13,290 have a Medicaid amount associated with that code. And of that, and I kept in the spreadsheet the minimum and the maximum just to kind of get a sense as to what percent of all the codes did Medicaid have the minimum allowed amount. And obviously, those amounts are kind of put on the Medical Center because Medicaid doesn't really negotiate with each hospital individually. But of those codes that had a Medicaid amount associated with them, 8,279 or 62 percent were the lowest and the spreadsheet has a minimum and maximum amount. So I don't know if that's good data or bad data. It certainly has a high probability of being misused. But I worry as we go through our regulatory processes that this brand new source of data that is very complex is going to be a source of information that we're going to have to tangle with one way or the other because I think people are going to use it. It's public data and dozens of different stories that it can tell. So that's something I'm thinking about is just how as an organization we get our arms around this in a fair and thoughtful way using the data for our purposes where we really scrub it hard and we feel that we can rely on it, but also working with our stakeholders elsewhere, whether it's the healthcare advocate or whoever to make sure that the data doesn't get used in a way that's misleading. So that's not a question. It's just an observation. Thank you, Tommy. Other board members? Yeah, I would just echo. I went on to a couple of hospital websites to look at what's out there and there's a lot of information. I mean, when you go in for a code, I agree with what Sarah was saying at the beginning. You may think you're going in for one thing, but it could be something different. If you go to a dermatology visit and then you could look at all the different things they could do and the different costs it would be to remove something by code, I think the average consumer wouldn't really know how to do that. But I also saw in some hospitals they are listing every single insurer and what they're being reimbursed by that insurer and other hospitals that maybe I didn't find the right places, but just kind of gave a range that said it went from X to Y. So it's harder to compare from that front. But just a comment on something that you brought up, Kevin, I mean, I think from a self-insured world, yes, there could be incentive to have people look around for pricing. But being on the corporate world side, I'd say there's a big but which is we're a pretty litigious society and should something happen because even though it may have nothing to do with that they went to a different hospital that costs less, but if something happened, you could imagine someone trying to come back at their employer because they recommended going to hospital X versus hospital Y potentially because of price. So I agree it's something from a self-insured world, you only pay what you spend and you want it to be less. I think employers tend to stick out of the recommending where people go because of HIPAA and other things. But that'll be interesting to see how that plays out and if employers go there. But it would be great to be able to benchmark against the hospitals for some of the procedures. But the other caution there is without looking at the entire universe, a hospital could be high in one area, low in another area. And I would caution jumping that we could jump to a wrong conclusion if we looked across one code and said, oh my gosh, this hospital is much more expensive than another without looking at all of the codes. There may certainly be outliers. There may be a hospital that's higher on every single one and one that's lower on every single one, but those would be things. I think as we look forward into this, how could we use it? It'll be interesting. But it's a new thing we'll be looking at starting in 21 for sure. Yeah, and just to piggyback on that, for a member of you, this certainly doesn't incorporate any quality directly in it, nor does sometimes the thing that's cheapest on a unit cost basis doesn't end up being the least expensive when you think about readmissions or things getting unintended complications. So without the quality or kind of the population health perspective, sometimes it can be short-sighted to kind of do just a procedure level comparison. Any other members of the board? Sure, I'll happen just a quick question for you, Sarah. Have you, and this is probably too soon to tell because I know you're just starting to dig into the data, but I'm curious about, I know the federal government mandated the first, was it 75 shoppable services, but then there was a lot of latitude for the other 225 or so hospital choice? And I'm just wondering if you've looked at the variation there in terms of is it all across the map, or was there sort of some consistency? And this is probably too soon to tell, or have you read about other people who have analyzed this? I'm curious about the 225 that were not mandated. Is there anything information that we're sending yet? Yeah, and I think what makes it challenging is that's kind of the set that could be shown to consumers in such a variety of ways. So I'm trying to figure out, I might have to do some web scraping to get at the data feeding the web tool, for instance, to even get at some of those comparisons. And then I think an important first step is trying to see if those tools and the information presented in the consumer-friendly way are actually jiving with the machine-readable entire manifest. And I think that's a really important place to start because it's much easier to work with a machine-readable file from a data perspective. But if it's not jiving with the consumer-facing one, that's a really important place to start about why that might not be true, which I could think of lots of reasons just given some of the latitude. But yeah, so I think that's kind of making it really difficult to get at that really basic question, unfortunately. Yeah, and I'm just thinking from an entrepreneurial standpoint, this is a treasure trove of data, and I'm just wondering if there's any third parties out there that are all over this in creating some kind of, you know... Yeah, I predict a lot of resales. They're going to do all the web scraping and they're going to pull this together. They're going to create tools for lots of states and consumers to use. I mean, I'm thinking there are entities out there that are going to be prepared to do this and have all the resources available to them. Is there anything that you've heard of of some third party that's doing this? I'm not aware of anything off the top of my head, but yeah, I fully expect a lot of resellers and data companies to be doing just that. Unfortunately, if it's garbage, then I don't know. I was more like an healthcare proctor institute or something like that. My last question was... So we've talked about consumers using it potentially, although it'll be complicated. We thought about how the board might be able to use it, caveats and all. And I'm wondering, is there any been conversation about how insurers are going to use this to do some comparisons of how they're doing in bargaining with hospitals? And just curious. Yeah, I haven't been privy to those conversations. So yeah, that's something else we can certainly monitor. Well, thanks. And I can't wait to see what we all do with this. This is interesting, although I do think to Tom's point earlier, a user's guide or some sort of... Here are the caveats before the data is misused or misinterpreted, I think is really important. And to the degree that the Green Mountain Care Board and the data team have some insights into that, I think it would be helpful to push that out there so that it isn't misused, because I do worry about that. Okay. Are there other questions from the board? Hearing none, I'm going to open it up for public comment. And I'm going to call on Eric Schulteis from the Healthcare Advocates Office first and Mort Wasserman, you're on deck. Thank you, Chair Mullen. I just... I mean, so I echo concerns expressed by the board and by Sarah. I think in response to the 70 mandated shoppable services of mandated 70 services that are required, it gets a bit tricky looking across the hospitals, just because we have a large number of small hospitals. So they are allowed, if they don't provide the service, to add additional services to get up to the minimum required disclosure of 300. So it's not like every hospital in Vermont is going to disclose these 70 services, because quite a few of them don't provide them all. I just wanted to hit on another topic, this idea that Sarah already hit on, kind of what a big task, working with the data is in addition to the different sources and whether it's a web tool that you have this website that you have to scrape or these machine readable files, it's not in a structure that is particularly useful for data analysis. It's pretty clear that different hospitals are structuring it different ways. So kind of restructuring the data and so it allows for comparisons across hospitals is a very non-trivial task and in my opinion, it's going to take a lot of work to do that. Kind of on that end, I think, you know, at least in my limited experience with an MC was that they were very interested in working with me and helping me understand, for instance, you know, was a no value for a specific procedure? What did that mean? Was it a zero? What does it mean? They're not allowed. They don't provide it for that carrier. So this seems to be a great opportunity to maybe work with VAAS and the individual hospitals and the carriers to kind of attempt to make cross system comparisons, the whole project of creating a database to do that more tractable. Because I think for any individual entities, just going to be too much work. And yeah. And then lastly, I mean, this data is going to be coming out every year. So as we're thinking about how to design this and set this up, I think we should think we're going to need to think a little bit past the immediate term and structure the data so that, you know, when this new data comes out every year, we're still able to implement processes to allow the analysis to be done. And I think it does require a little forethought to try to think about what might be done in future years with releases. Thank you. Thank you, Eric. We're going to move to Mort Wasserman and Mike Deltrecco is on deck. Mort. Hi. I have a question for Sarah and then a comment. What proportion of Vermonters have high deductible plans? The sorts of plans that in theory, price transparency is they're supposed to help those consumers. Oh, boy. You put me on the spot here, Dr. Washington. Sorry. Not that many. You know. Yeah. It precisely it's growing, but it's still not the majority. All right. No, it's nowhere in your majority. If I understand it correctly. So I was glad, Sarah, that you pointed out that this whole idea of shopping around for services flies in the face of a value based care all payer model as far as I understand it. And it really depends on economic theories, market theories that apply somewhere between poorly and not at all to individual consumers in terms of the way they make decisions about what to do in healthcare. So I would, although this is a lot of data and it's very tempting, it's also in typical fashion, not it is not structured uniformly. There'll be a tremendous amount of work involved to try to allow one to compare it from one hospital to another. So I don't I think if there's a limited amount of time for the data team to be doing stuff in 2021, I'm not sure this is where I would invest resources. Thanks. Thank you more. Mike Del Trucco. Good afternoon, everybody. Can you hear me and see me? Yes. Perfect. So first of all, I wanted to thank Sarah and the and the board for their thoughtful comments. And additionally, the public other public commenters. You know, this is a new data set. You've heard all of the challenges and from the get go, our members have really stressed call your hospital. And it's not only call your hospital about what code you're going to or what procedure or how do I estimate out of pocket. It's also about accessing cherry care policies. It's also accessing other programs that may be available, getting insured if you're not insured. So it's a whole host of things that we want to attach to aside from this transparency. So if there are any patients listening to this or they do listen and you use these tools, please reach out, look at your hospital's websites. It's pretty clear who you call and how you get help. So reach out and call. And to the to Eric and the other patient care advocates on the phone. If there are patients that have issues, challenges that you hear of, I am available to make sure you get the right connection to the CFO or whoever it might be at the hospital that there may be an issue. Thank you. Thank you, Mike. Is there other public comment hearing none? Thank you, Sarah. As more has said that it may be fraught with the inability of use, but I have tasked you and Patrick to take a look at this to see if there are possible constructive uses that make sense for the board. And so we look forward to at least conducting that analysis and not spending too much time, but the right amount of time to determine if there are uses that would be helpful and constructive. So thank you for your work today, and I thank you in advance for your work in the future on this. Sure. And we look forward to updating you next week about all the other stuff we're up to, so we can have a conversation in context. Perfect. All right. Thank you. Thanks. Is there any old business to come before the board? Is there any new business to come before the board? Hearing none, is there a motion to adjourn? So moved. Second. Is there a second? Second. Thank you. All those in favor of adjourning signify by saying aye. Aye. Aye. Those opposed signify by saying nay. Thank you, everyone. Have a great rest of the day.