 Good afternoon and welcome to the Green Mountain care board. My name is Kevin Mullen chair of the board and I will call this meeting to order. I will start with the executive director's report and I will fill in for Susan Barrett to deliver that. The first thing that I want to announce is that posted on our website, our letters that we sent to both. UVM health network and to the parties to come to agreement. It's shameful that 1800 for monitors are being held hostage through this negotiation and we're hopeful that the parties will come to terms or at least agree to an extension so that they continue to negotiate. So those letters have gone out. Also on our website we have you can find the link to give public comment on hospital budget guidance. That will be open until March 21st next Monday and will be extended if we don't vote on guidance on Wednesday the 23rd. We also have the open public comment regarding the next agreement that has been on the site and that is there as well. The next item on the agenda are the minutes of Wednesday, March 9th. Is there a motion? So moved. Is there a second? Second. And moved and seconded to approve the minutes of Wednesday, March 9th. Without any additions, deletions or corrections. Is there any discussion? Hearing none. All those in favor of the motion please signify by saying aye. Aye. Any opposed please signify by saying nay. Let the record indicate that the motion passed unanimously. Next on the agenda is a discussion on clover help. And we will turn it over to Marissa Russ, Julia, Patrick and Michelle. And Marissa, I'll ask you to tee it up. Great. Thank you, Mr. Chair. Good afternoon, everyone members of the board. I'm going to go ahead and share my screen. Is that visible for everyone? Yes it is Marissa. It's all set. Great. Thank you. So again, good afternoon. We're here today to share with you our staff analysis and recommendations on the FY 22 budget submission for clover health partners. My name is Marissa Melamed. I'm associate director for health systems policy with the Green Mountain care board. And I have with me several members of our team to help present today Russ McCracken with the legal team, Julia Bowles and Michelle Sawyer with our policy team and Patrick Rooney with our finance team. This is the agenda for today. Russ is going to start by reviewing the board's authority and criteria for the review. Julia and I are going to give you some relevant background information and an overview. The elements of the budget review consist of both policy and finance. So we will, different members of the team are going to talk about different aspects of that. We're going to present to you our staff recommendations as we go. And then we'll finish with a summary of the staff recommendations. Turn it over for board questions and discussions and opportunities for public comment and then next steps. I'm going to turn it over to Russ for the next couple of slides. Thank you, Marissa. I'm going to start by framing the regulatory process that the board has for this type of ACO. Broadly, the board's overview and regulation of ACOs is made up of two different processes. The first is certification and the second is an annual budget review. Certification is only required for an ACO to be eligible to receive payments from Medicaid or commercial insurance. That requirement is set by statute. And as Clover Health receives neither the question of certification for Clover Health is not before the board. So in other words, the board is not, sorry, the board is not asked to decide if Clover Health may operate in Vermont. Under the statute and the rule, the board annually reviews and modifies or approves ACO's budgets. That aspect of the statute and rule do apply to Clover Health. Next slide, Marissa. The budget review under statute and rule is different depending on whether an ACO has more or less than 10,000 attributed lives in a budgeted year in the states. Clover Health is well under that 10,000 attributed lives threshold. And so we have a, we follow a particular process for them that differs slightly from other ACOs. It's the first instance of an ACO that is Medicare only in less than 10,000 lives before the board. So staff developed specific guidance for this type of ACO that was then reviewed and approved by the board last year. Regarding the scope of the board's jurisdiction, there are two points that I wanted to note here. First is that the parameters and terms of the CMS direct contracting model and its replacement CMS's ACO reach model are set by the federal government. And the second point is that the board in Vermont statute govern conduct in Vermont and can't govern conduct that's either directly or by practical effect that is outside of the state. There's case law that delves into the nuance of both of these points, but I will for purposes of this discussion leave just those general statements. Also to note here that in addition to the budget review, the board can require an ACO to report certain data and analysis. That's part of the board's authority under rule 5501. And lastly, as the board is familiar, but as a public refresher the procedural history here. Clover Health requested a waiver of the budget review process in 2021. It was reviewed by the board in 2021. The board declined that last summer. The staff developed some guidance for Medicare only ACOs with fewer than 10,000 lives, which the board reviewed and approved in 2020 in October, rather. And Clover Health's budget was submitted December 31st of 2021. Next slide, Mercer. This is the, this is an excerpt from the board's ACO oversight rule. It's rule 5405 part C and it applies to ACOs that have fewer than 10,000 attributed lives in Vermont. We have here for criteria that the board will take into consideration. And what I wanted, what we wanted to focus on here in particular is part two, the bold and highlighted aspect is that differs from the board's review for ACOs that have more than 10,000 lives. The board can select the criteria from 18 BSA 93 82 that the board deems appropriate to the ACO size and scope. On the next slide, we have some staff suggestions about which criteria. The board should focus, which of the statutory criteria the board should focus on for Clover Health in light of their size, presence and scope of their operations in Vermont. I won't read through all of these here, but generally it's information regarding utilization of the health care services. The effect of the care model on appropriate utilization and the provision of innovative services character competence fiscal responsibility and soundness of the ACO. Reports from professional view review organizations or the ACO's efforts to prevent duplication of care and integration with the blueprint for health in its regional care collaboratives. As continues on to the next slide, the board would consider public comment from information that's gathered from meetings with the ACO information on the ACO's administrative cost. The extent to which the ACO makes its cost transparent and easy to understand. The extent to which the ACO provides resources to primary care practices to ensure care coordination and community services are delivered to patients. And I think that we throughout this presentation. These are the kind of overall criteria and factors that we've tried to focus on and presenting presenting the information here. So what's there are 16 criteria in 93 82 what's not listed here. Generally are factors that staff thought given the limited size and scope of Clover Health's operations at least for the current year was less important to focus on. There are additionally some factors that were not applicable, such as the effect of Medicaid reimbursement rates. I do want to note that in the factors not listed here that the staff haven't focused on. There are some valuable population health initiatives and systemic health care investment criteria. But our view was given that Clover's presence and is limited to one practice and roughly 1800 aligned beneficiaries. And given that it's operating within the scope of a established Medicare, right, the scope set by Medicare for its ACO model. The staff felt that that wasn't as essential a factor to consider this year. I do think it's worth noting and we'll get into it a little bit further on with respect to those factors that the direct contracting model is being replaced with an ACO reach model. That may help address some concerns in that area. So with that, I'll turn it back to you. Thank you. I'm going to start with a high level overview of what we're talking about. What is Clover? What is direct contracting? We did introduce the entity in the concepts back when the board reviewed their initial request in June. But we want to make sure we're clear what we're talking about here. So Clover Health is participating in the Medicare direct contracting or DC model. And the DC model builds on the next generation ACO model with several new model design elements. And its intention is to bring more Medicare payments from fee-for-service into value-based payment arrangements through two voluntary risk sharing options. So the model was originally slated to run from 2021 through 2026. However, it was announced late in February that the model as it is currently operating will end at the end of this year, 2022, and transition to the ACO reach model starting in 2023. And we will talk about that a little bit more. The risk model under the DC agreement is that the DCE or the direct contracting entity bears full upside and downside risk or the risk model that they are operating under. And it is a higher risk than we see in our other ACO arrangements. Who is involved? So the agreement is between CMS and the direct contracting entities and then providers who contract with DCE. It does not change to members' Medicare enrollments or it's not Medicare Advantage. A DCE is essentially the same thing as an ACO. It just was renamed in this model. And in the ACO reach model, these entities will again be known as ACOs. Clover Health Partners is a multi-state direct contracting entity that is contracted with Vermont providers. They agree to be accountable for the cost and quality for aligned beneficiaries. And the providers have access to the Clover Assistant, which is a point of care tool offering clinical support and other capabilities. So that as Clover presented, that is a value add that they say that they bring to the providers. So we felt it was important to understand the impact on Vermonters who are aligned to this model. And the agreement is not, it doesn't change Medicare beneficiaries agreement or contracts with Medicare. This is an agreement between the direct contracting entity and Medicare. However, beneficiaries are aligned to this model similar to ACO alignment and other models. The beneficiaries who are aligned to the DCEs are still in traditional Medicare. They have access to the entire traditional Medicare network. The alignment to the DCE does not affect their out-of-pocket costs and premiums, except in the case of some benefit enhancements on cost sharing, which we'll mention. But it does not change their, you know, their premiums and out-of-pocket costs of their contract with under their Medicare, traditional Medicare agreement. It does not affect the use of supplemental insurance. DCE attributed beneficiary rights in the DCE participation agreement include beneficiary notifications that they are aligned, beneficiary freedom of choice, and the rights to opt-out of data sharing. Again, this is similar to other ACO arrangements that we review. And in addition, as I mentioned, through the DCE providers, the beneficiaries may have access to additional benefit enhancements, including coordinated care between the DCE participating providers and preferred providers, and access to benefit enhancements, which we will touch on a little bit, a little bit more. And again, this is not a Medicare Advantage. Clover Health, the parent company, does operate Medicare Advantage plans, but Clover does not offer Medicare Advantage plans in Vermont. We wanted to highlight for you the public reporting and transparency. This is lifted directly from the direct contracting model participation agreement. We, since their, you know, our recommendations are going to center around reporting. We want to make sure it's clear what they're already required to publicly report and post on their website. Name and location of the entity, primary contact information, identification of all DCE participants and preferred providers, by state, identification of all joint ventures between or among the DCE and any of its DCE participant providers and preferred providers, identification of the DCE's key clinical and administrative leaders in the name of any company by which they are employed, identification of members of the DCE's governing body and name of any entity by which they are employed, and public reporting includes shared savings and shared loss information, including the amount of any shared savings or shared losses for any performance year, the proportion of shared savings invested in infrastructure, redesigned care processes, and other resources necessary to improve outcomes and reduce Medicare costs for beneficiaries, and the proportion of shared savings distributed to DCE participant providers and preferred providers. And the final one is the DCE's performance on the quality measures described in the agreement. And Clover does have the information that is currently available post on their website. They've also submitted this information to us. However, shared savings and loss information quality performance, those, that's not available yet. I want to make a quick note on integration with the Vermont all-pair model initiative. Just a couple of things to keep in mind. The DCE model participants or participants in the DCE model, so the participant providers cannot also participate in the Medicare shared savings program or other Medicare shared savings initiatives. Basically you can participate in one Medicare program, but not multiple. So participants in the Clover program cannot also participate in the Vermont Medicare ACO initiative. And a staff analysis determined that Clover Health Partners program in Vermont is unlikely to qualify for all-pair model scale. I'm going to turn the next slide over to my colleague, Julia Bowles, who looked into information about the ACO reach model, and she's going to talk you through those talking points. Sure. Yeah, thank you, Marissa. So as Marissa and Russ noted, the DCE model is undergoing a redesign. This was just announced just less than a month ago. So I think everyone is still sort of digesting, but we wanted to make sure to give some of the high points. So CMS announced that they were redesigning the DCE model in response to administration priorities and feedback from stakeholders. The new model is called the ACO reach model, as you've heard, and reach stands for realizing equity, access, and community health. So this new model does retain many of the same features as the current DCE model, but with an added emphasis on advancing health equity, promoting leadership and governance, and promoting provider leadership and governance, and protecting beneficiaries through more monitoring. And current DCEs can transition to the new ACO reach model so long as they remain in good standing with CMS, as well as agree to meet the requirements of the ACO reach model by January 1st of 2023. And as Marissa mentioned, entities that are currently referred to as DCEs will be called to reach ACOs under this new model. So again, this was just announced in February, but if we can go to the next slide, we wanted to just hit some of the key changes that we felt were relevant to what we're going to be reviewing for the rest of this presentation. I do want to flag that at the bottom of this slide, there's a link to a CMS chart that in more detail than this slide walks through many of the granular changes to the model, but the ones that we wanted to highlight are listed here. So first, the model updates the ACO governance requirements. Under the DCE model, participating providers have to hold at least 25% of governing board voting rights. Under the ACO reach model, the percent will be increasing to 75%. And this new 75% number probably sounds familiar to folks because it aligns with the governance requirements in the Vermont Medicare ACO initiative participation agreement. And additionally, under the ACO reach model, beneficiary and consumer advocates have to hold voting rights, and these members also have to be separate. They cannot be the same person. So secondly, there is an added emphasis on health equity through new requirements and benchmark adjustments. So specifically, ACOs must develop a health equity plan and collect beneficiary reported demographic and social needs data. Also, there's a new health equity benchmark adjustment that has been added to better support care delivery and coordination for patients in underserved communities. And lastly, under the health equity section, there are new benefit enhancements that are being added to increase the range of services that may be ordered by nurse practitioners to improve access. And as Marissa mentioned, we will be going into more detail on the benefit enhancements under the current model later in this presentation. Third, there are a number of changes to the benchmarking methodology, but we wanted to specifically highlight the changes to the risk score growth cap, which were done to further mitigate potential inappropriate risk score gains. And finally, again, this is not an extensive list of the additional monitoring and compliance elements, but the ones we've wanted to go through here were that under the ACO reach model, there's additional monitoring and compliance efforts and analytics that will first assess annually whether beneficiaries are being shifted into or out of Medicare Advantage. They will be examining ACO's risk score growth to identify inappropriate coding practices. There will be an increased use of data analytics to monitor use of services over time and compared to a reference population to assess changes in beneficiaries' access to care, including stinting on care. And finally, audit annually reach ACO contracts with providers to learn more about their downstream arrangements and identify any concerns. So again, this is just a summary. I encourage folks to follow this link to check out the whole chart. And as a reminder, the ACO reach model is beginning January 1st of 2023. So with that, I will hand it back to Marissa. Thank you, Julia, for that great overview. We wanted to make sure people understood that the new model was only announced less than a month ago. We did review Clover's budget with this in mind given that it is March of this performance year. They're already operating under an agreement and the model will be changing. So ACO budget review is done annually for ACOs in Vermont. We're just gearing up to produce guidance or develop guidance for 2023. And so we will be looking at the Medicare-only guidance, you know, looking ahead to the new model that they'll be operating under. So Clover Health Partners budget was submitted December 31st of 2021. I'm going to go through the elements now of the budget submission. And that is where you'll see our recommendations emerge. So I'll start quick with a overview of the public comment that we've received today. We went all the way back for the purposes of this slide to the past public comments regarding the proceedings in June, where we accepted public comment on the request from Clover that the board waive the review and approval of Clover Health Partners annual budget. Commenters there generally opposed waiving the budget review. We went through a public process and on June 30th the board voted unanimously to deny Clover's waiver requests. So that was sort of the first round of comment that we received in the current review period. The board opened a public comment period ahead of today's staff analysis. We asked people to comment by the end of day Friday so we could review those prior to this presentation. We've not received any public comment as of Friday or today, I believe. We did work with the HCA as required and we submitted their questions as well as our own to Clover so that we felt like we had a complete review. So we thank the HCA for that collaborative process. And this is a reminder that the public comment period does continue until the board votes. Again, we ask that you submit them ahead of the vote to allow us to review any public comment, but the public comment period is not closed. So there's still opportunity to submit that prior to a vote. So here are the key areas of review. This is just based on the guidance. These are the six sections of the guidance. Basic information, the provider network, the payer program, information, budget and finances, the care model, and then any information to help us understand alignment with Vermont's all payer model. So just some quick basic information that Clover Health Partners is a direct contracting entity. They have been operating in Vermont since April of 2021 under the DC model participation agreement. All the materials that have been submitted to the board that are available to the public are posted on our website at that link if people have not had a chance to review those. And again, like we said, you had an introduction to Clover last spring. One thing we wanted to bring forward from that discussion is that there is a pending and ongoing shareholder litigation. This is ongoing Department of Justice and SEC investigations as noted in our staff presentation from June 21. There are multiple shareholder cases ongoing and appear to be generally related to Clover's compliance with disclosure obligations according to summaries of the litigation in Clover's annual 10K report filed with the SEC. Additionally, Clover's Medicare Advantage Plan is involved in multiple disputes by providers for underpayment including a lawsuit filed in New Jersey. There are no updates on the DOJ or SEC investigations, but one recommendation that we had given, you know, our review of this information is that we recommend that Clover Health provide to the Green Mountain Care Board semi-annual updates on any material pending legal actions taken against the ACO or its affiliates or against any members of the ACO's executive leadership team or board of directors related to their duties and any such actions known to be contemplated by government authorities. So we can be kept deprived of any updates there. The next section of the review is their provider network. So this is just the basics. They have two types of providers, participant providers. Those are primary care providers who can align beneficiaries and preferred providers for specialist and ancillary facilities to improve care management, quality and cost of care. Again, they serve familiar terminology with our other Medicare agreements that we review. The provider list is due to CMS in September for the following year. So this timeline again aligns with what we are familiar with. This is Clover's 2022 provider network in Vermont. It consists of one primary care practice in Burlington with a count of 20 providers and they have preferred provider agreements with five skilled nursing facilities in Vermont as well. Around the provider network, we didn't have any staff recommendations for 2022. And, you know, the reason for this is that network development questions are included in the annual budget guidance. So we do ask them and we did ask them some additional follow-up questions on through their plans so that we can understand as best as possible how they plan to grow or expand in Vermont so we can tailor our review accordingly. They do report their provider contract to both the Green Mountain Care Board and CMS. So we have a copy of that for examination. So we didn't feel like we had additional reporting requirements there. And so we felt as though we had the information that we needed for 2022 regarding the provider network. Moving on to the payer program. Of course, this is a Medicare only arrangement. So there's just the one program as Russ talked about in the beginning. The parameters are set by the D.C. participation agreement with CMS. The risk and payment options selections are for the entire DCE. So Clover who is operating in multiple states is making selections based on their full business. It's not by specific to state or provider. Attribution is claims-based or by voluntary alignment of which Clover stated they have both in Vermont. This is a high-level overview of how the funds flow through the model. This diagram is a high-level view. And again, these parameters are set in the Medicare participation agreement. So I'm not going to speak for Medicare here, but we wanted to present this so that we have kind of a high-level understanding of how this works. And it should be fairly familiar. The key takeaways, this is still a fee-for-service model with CMS paying for most care by a fee-for-service. So that's the area, that's sorry, that's the arrow from CMS to the providers. Those are fee-for-service adjudicated claims. Clover has opted into the primary care capitation model. So the payments that are passing from CMS through Clover to the providers are for primary care payments. So that's what it means when it says, fee-for-service adjudicated claims excluding primary care. The primary care is those payments that are flowing from CMS to Clover to the providers in those arrows in the middle. There is a quality element through potential shared savings or shared losses in the form of a quality withhold. And providers receive payment for using the Clover assistant, the point of care tool offering clinical support and other capabilities. So CMS is paying Clover a capitated payment, and then Clover is then passing that through to providers. And the pass-through allows for Clover to, you know, implement their specific model, which in this case is adding the Clover assistant payment, which they feel improves the quality and the value of the care. The shaded arrows are the potential shared savings and losses. So this is to highlight that shared savings are passed from CMS to Clover, and they can share those savings with their participant and preferred providers according to their contractual agreement. Clover does hold all of the risk in this arrangement, so shared losses are paid from Clover back to CMS, and they are not, you know, the providers are not on the hook for any shared losses. So a risk model, this is an upside-downside model. The direct contracting entity has potential for both shared savings and shared losses, as I mentioned. There are wide risk corridors compared to other AC arrangements in Vermont. The direct contracting entity bears 100% of the risk at less than 25% of the performance year benchmark. The savings and loss rate decreases at greater than 25%, so there are four risk bands, and the participant-preferred providers bear no risk. The DCE collects any shared savings and pays any losses. This shows you the risk corridors and the four risk bands, so the risk corridors are automatically set under the CMS agreement. Clover has selected the global risk sharing option, which is highlighted below. And again, this slide is just to show you the option that Clover has selected under the model. And again, we're showing you these for informational purposes. These are set by the Medicare agreement to give you sort of familiarity with how it works, but the, you know, the board doesn't have authority to adjust any of this. It's all part of the participation agreement. So like the Vermont Medicare ACO model, the total spending is compared to a performance year benchmark, the expected total cost of care, which is adjusted for population risk score among other factors. So in the case of Clover in Vermont, there's about 1,800 aligned beneficiaries expected in 22. This is a minimal change from 2021. The benchmark is set prospectively. It covers all part A and B Medicare expenditures. And as Julia mentioned, CMS is continuing to address concerns about increased coding intensity through modifications in the ACO reach model. There's a pretty complex specification for how the benchmark is set. We're not giving an exhaustive review of that here again because we don't set the benchmark in this case as we do for the Vermont Medicare ACO arrangement. Regarding shared savings and losses, Clover presented or submitted some results to date on their direct contracting margin. Those are all the results that we have at this time. The final settlements for the final financial settlements for both 2021 and 2022 are to be reported in July 2023. So they will have preliminary results in July 22. I think the intention is generally to have it approximately seven months after the end of the performance year. However, for 21, it's not going to be finalized until 19 months. And for 22, it will not be finalized until seven months. So both results will be reported in 2023. So that brings us to the end of the overview of the payer program arrangement. The recommendations that staff came to in this section is that Clover Health provides to the Green Mountain Care Board its shared savings segmented for Vermont. So as we showed you in the beginning, they are required to report their shared savings. That would be at the entity level. It looks like they're required to report them by participant and preferred providers. We would like them to report it for Vermont specifically when those results are available. And again, some key points here that I think we've probably been pretty clear on at this point is that those arrangements are set by Medicare. We do have that agreement so we can examine it. We don't have additional reporting needs there at this time. And then there are new requirements in the AISO reach model around governance, health equity, and additional monitoring compliance that will come on board in 2023. So we had contemplated maybe some additional reporting about some of these areas, since it looks like they're being addressed in new ways and AISO reach. We will wait for that, you know, for the 23 review to take a look at that. That brings us to the end of the payer program section. The next couple of slides, I'm going to hand over to Patrick who took a look at the financial information. Thank you, Marissa. Good afternoon, everyone. Yes, we did review the consolidated statements of clover health investments and subsidiaries. I'll try to refer to them as CHI as I've moved through some of my comments, which does include clover health partners. And I'll try to refer to them as CHP. That's the direct contracting entity that's central to this discussion. At the consolidated level, it's very difficult to carve out CHP's contributions to the overall financial position and the results that are posted. What I could not find and I was hoping for was a schedule of various financial statements that would show the line items down the vertical axes and then the different entities' contributions to revenue and consumption of resources or expenses that contribute to the overall consolidated look, but I was not able to find that type of perspective. So that made it very difficult to understand the financial makeup of the entity that we're dealing with here. What we can see at that consolidated level is that CHI is in a stage of very rapid growth with fiscal year 21 revenues growing roughly 119% over their prior fiscal year, rising to about $1.47 billion. And additionally, that that year-over-year growth is being driven by the direct contracting segment of Clover Health investments, otherwise known as CHP. We know from the responses of Clover that CHP is the only direct contracting entity within CHI, which confirms that CHP is largely responsible for a lot of that rapid growth of overall revenues from the consolidated perspective as that business segment came online in 2021. Revenues derived from the operations of CHP began in the second fiscal quarter. And for this entity, that would be April through June 2021. And as of year-end accounted for roughly 45% of the total consolidated revenues of CHI for that fiscal year. And that's 45% is based on only three fiscal quarters of activity. So you can project that forward and you can see that that growth is likely going to be much higher once they put a full year of operating activity under their operating results for 2022. So it's very impactful. Additionally, operating expenses have significantly increased year-over-year, rising 175% up to $2.1 billion, likely because of activity related to CHP. Specific line items of note, as you can see on your screen, where there were major increases driving that overall growth in expenses was net medical claims incurred, up 163% over prior year, salaries and benefits up 266% over prior year, and general administrative expenses up 54%. With all of this activity, the net margin continued to erode falling from a loss of $137 million in fiscal year 20 down to nearly $588 million in fiscal year 21. As of the conclusion of 21, CHI and subsidiaries has an accumulated deficit of about $1.6 billion. However, the balance sheet had a marked turnaround despite these losses. So it appears that there's been some significant capital infusion activity that has occurred during the course of 2021, which has increased the cash position of CHI significantly in driving those assets up 256% over their prior year. Liabilities had a slight downward shift, about 5%, and the other marked balance sheet activity was that the equity position completely turned around and has posted a more solvent state at $539 million in the positive from negative $617 million in the year prior to that. So there's a lot of shifting activity there. This is a company that's from a consolidated level that is growing very quickly. And there's going to be significant activity, I'm sure, as that direct contracting entity shifts into this new model. And so with all of that said, it's very difficult to understand where CHP fits into this overall financial puzzle from the consolidated financial documents. Because of the opaque nature of those, from that consolidated approach, our recommendation is to collect audited financial statements that show in some way the contribution of the direct contracting entity to the greater whole, as I spoke to earlier. This is our recommendation, as I said, it's very difficult to understand the company that we're dealing with when financial activity is folded at a larger consolidated perspective. And additionally, with this level of growth, the auditor's notes that would accompany the audit may provide us with several insights that could lead to a more thorough understanding of the organization and its resulting financial activity. So in closing, this is not information I think we need for this review specifically. But if Clover does intend to expand their presence in the state of Vermont, it would be information that we should seek as we move forward. And I will note that on the prior slide in the last 24 hours with Clover's response is they have told us in all fairness to them that their fiscal year 21 audit have been posted and those, I've reviewed them today, those do have auditor notes. So that's some new information that we've received in the last 24 hours. But with that, Maricel, turn it back over to you. Thank you, Patrick. I did mean to note earlier that we did receive those responses to questions and we received them yesterday without time to fully incorporate them. So thanks for your quick review there, Patrick, on that. And if there are other significant areas from those responses that change any of these recommendations, we would let you know before the vote if there's anything else that we note from those responses. Next is, I'm going to pass it over to Michelle Sawyer. I'm just going to talk about the model of care review. Thank you, Marissa. So as Russ mentioned, the staff determined that there are a number of criteria from the statute that should be considered when reviewing Clover Health Partners. The criteria on the slide are the summary of the ones that we feel are most applicable to Clover's model of care and population health program. As a reminder, Clover is present in only one primary care practice in Vermont with less than 2,000 attributed beneficiaries and so we would not expect broad population health initiatives this year in light of the limited size and scope. Next slide, please. So when we reviewed Clover's model of care, we determined that these aspects of the model listed here supported the corresponding review criteria. These are not siloed criteria. There's many examples where an aspect of the model might support more than one of the review criteria, so there is some overlap. So looking at strengthening primary care, participating providers receive full Medicare fee for service rates plus for services, plus the additional flat payments for use of Clover Assistant, which is their point of care technology, which will be further discussed on the following slide. There may also be shared savings earned by the provider. Within Clover Assistant, there is a point of care quality gap alert and feedback on quality measure achievement as well that's accessible to the providers. Clover Assistant also provides evidence-based care recommendations at that point of care. And for supporting appropriate utilization, again, providers have access to that evidence-based care recommendation in Clover Assistant. Clover has a complex care program where there is a focus on care coordination, access to care, and health outcomes for highly complex patients. ADT alerts, those are the admission discharge transfer alerts, are built into Clover Assistant, which is fed in from the Vermont Health Information Exchange. Care coordination services are available from social workers and nurses telephonically. These care managers can make both medical referrals and non-medical referrals to services to support housing needs, transportation, financial assistance applications, and more. Clover Assistant has a telehealth module to improve patient access to care. And Clover is participating in Medicare benefit enhancements and engagement incentives, which will be reviewed in more detail later. The next two criteria, integrations with community providers and the prevention of duplications of services. So Clover is working to build a network of providers, which are providers of services such as home health, skilled nursing facilities. Clover Assistant provides the ability to make referrals to those local providers. Again, those ADT alerts help providers know when their patients have had a transition of care. Care coordination is available. Clover has stated that these services, while they are available through them, if they're also available through Blueprint or another initiative that those efforts would not be duplicated. Associate Economic Pharmacy and Lab data are all, and Medicare claims data are all available in Clover Assistant. After an inpatient stay, providers are prompted to complete a medication reconciliation. And finally, clinical data sharing capabilities are available within the Clover network through that technology. If data were to be shared with other providers outside of the network, Clover Assistant allows for the provider to share Medicare claims data with those providers. Next slide, please. A little bit more about Clover Assistant. Much of the qualities of their care model discussed on the previous slides are built into this technology platform. All network providers are given access to and trained to use this technology, which will either integrate directly into the practices EHR or will function as a web-based application. Providers are expected to access Clover Assistant with each patient visit and are incentivized to do so by receiving a fixed dollar amount for each time it is accessed. Clover makes these payments to providers on a weekly basis. The Clover Assistant has many capabilities, a few of which are highlighted here. They are connected to our Health Information Exchange, which enables those ADT feeds. This allows for providers to receive alerts when their patients are admitted, discharge transfers from hospitals, nursing homes, home health agencies. And providers have access to three years of Medicare claims data and have access to some lab data overnight. Regarding population health efforts, Clover Assistant provides real-time quality of care gap alerts to providers, as well as quality measure feedback. Providers also have access to socioeconomic data for their patients, which can allow for better person-centered care and consideration of social determinants of health. And referrals can be made within Clover Assistant and care coordination is available from those care managers as well. Next slide. So the benefit enhancements and beneficiary engagement incentives. As part of the DC model, CMS allows DCEs to choose to offer these enhancements and incentives. Clover's decided that they would offer all of the options from CMS. They are all listed here. So these are the ones that all of the attributed beneficiaries through Clover, they would have access to these. Next slide. All right. The quality measures. So on a quarterly basis, CMS will provide data regarding the DCEs or Clover's performance for a prior quarter of the agreement performance period on quality measures that are listed here. And the reporting and data sharing overview for the last 12-month period that ends on the last day of the relevant quarter. You can see that the measures, the asterisk measures align with our APM quality measures. And it should be noted that that CAP survey, that is paid for by the DCE, not the provider. So the provider does not bear the cost of that survey. It is unknown at this point how any of this will shift with the ACO reach model. Right. Last slide, please, Marissa. So finally, our recommendation around the care model. So we recommend that Clover Health provides the board its quality reporting segmented for Vermont, but with appropriate restrictions to protect patient confidentiality. Thank you. And I'll turn it back to Marissa. Great. Thank you, Michelle and everyone. So this brings us to the summary of our recommendations. And again, the board is not voting today. So we can open it up for discussion. But our recommendation at this time is to approve the Clover Health Partners FY 2022 budget as submitted subject to the following conditions. Clover Health provides to Green Mountain Care Board its shared savings segmented for Vermont. And I think a clarification we might add there from their public reporting requirements is also segmented by participant and preferred providers. Clover Health provides to Green Mountain Care Board its quality reporting segmented for Vermont but with appropriate restrictions to protect patient confidentiality because we understand there is likely a small numbers or there may be a small numbers problem here and it's currently one practice. We to collect the audited financials indicating their balance sheet and statement of operations contributions submit a standalone audit for CHP if it's available. It sounds like we may be able to tweak that a bit based on the information that we recently received. And then the final one where we started was that Clover Health provides to Green Mountain Care Board semi-annual updates on any material pending legal actions taken against the ACR, its affiliates, et cetera and we can set what the appropriate schedule would be for that. So with that I will turn it back to you Mr. Chair for Board questions and discussion, public comment and we can discuss when a potential vote may be appropriate. Thank you. Thank you, Marissa. I'll open it up to Board members for any comments or questions. Do any Board members have comments or questions? Yeah, I have a few. So I'll kick it off. Just let me and I'm going to try to filter these filter out the ones that were answered by the presentation. I don't have a lot, but I have some. My first one is just kind of stepping back and saying why are we doing this now when the whole model is going to change in just a few months? Why go through this process when the ACO reach process will begin in 2023? I'm just wondering if staff have any insight into what the strategic advantage or what any advantage might accrue to COVER health partners by starting as a direct contracting entity and transitioning to an ACO reach entity in 2023. Russ, do you want to take the why question? Sure. Let me, I'm happy to try that. The why question, Clover came before the Board in June. They asked to waive the budget process. The Board declined to waive the budget process and instructed us to put together some guidance. So we're going through a budget process. We didn't know in June that the whole model was going to change. We didn't know that until a couple of weeks ago. So we have this annual budget process. And so we've been going through it. In terms of whether there's any benefit to an ACO starting as a direct contracting entity and then moving, I don't think that there would be. And I say that because the way that as we understand the new CMS model is going to work, effective January 1, 2023, the ACO has to be fully compliant with the requirements of the ACO reach model. And that's regardless of whether they started as a direct contracting entity or whether they're a new entrant who applied to join the program directly into the ACO reach model. Thank you. My next one is kind of a line of that is the ACO reach model is going to change the board structure of the ACO from 25% providers to 75% providers. And that's a good thing. But I'm just wondering if as an ACO, Vermont is such a small piece of the ACO pie, whether it's a direct contracting or an ACO reach, would we have any expectation to have any people on that board for it? Because the board is for the ACO entity as a whole, not just for the Vermont portion of it. So I'm just wondering, you know, and so there's probably thousands of hundreds of providers that are engaged at the entity level. And my guess is that we, we wouldn't have much of a chance to have a meaningful participation at the board level. Yeah, I think that's, sorry, Marissa, I think that's also a question for Clover. The boards, you know, you are absolutely correct that Vermont is a small percentage of there, of the Clover Health ACO's overall network. Okay, so my next question has, from the report I should have written the page down here, but it says Clover Health has historically used telephonic nurse care managers and social workers. And so my question is, are these folks at Evergreen or are they out of some out-of-state phone bank or where are these people? I'll take that. Thanks, Tom. That has not been clarified. I am pretty confident in assuming that they are not local Vermont providers, that they are contracted through Clover Health partners more broadly. Thank you. So this, this is some data that was from Clover investments fourth quarter filing and their 2021 filing. And for the DEC beneficiaries, there was a little chart in this article that showed that as of December 31st, 2020, there were zero DCE beneficiaries in Clover. And at the end of December, December 31st, 2021, there was 61,876. So obviously that's a lot of growth, but still 61,876 is still only about half of the Medicare population that we have in the state of Vermont. That being aside, there are these preliminary quality reports that are due at CMS for program year 2021 on July of the, they're due July 2022. And I'm just wondering, given that the number of DCE beneficiaries grew from zero to 61,876 in program year 21, how, how was that distributed through the year? Because I would think that would have an effect on quality reporting if, if all of these folks kind of were enrolled at the near the end of the year, that's a very short period of time, as opposed to most of them were at the beginning of the year. So I'm just, so that's just a question I'm raising, you know, about the quality reports that, that, you know, that we might not have any, any meaningful quality reports on the DCE folks until 2024. I can make a clarification there for you, Tom. And again, I'm not going to speak for Clover. Clover's represent, representation is here. So they, you know, can answer questions, but the performance year didn't begin until April of 2021. So there wouldn't be, that was the, that was the first performance year. So that is when, you know, any aligned beneficiaries would have come on, on board. Yeah. And this is Kevin Murphy. All of those aligned beneficiaries would have been aligned April 1st. So we start with that number and we end with a number similar to that. Obviously we lose people to death and moving out of the service area or moving to MA, but all were originally aligned April 1st. So, so just to be clear, so I'm looking at the number 61,876 at the, in December of 31st of 2021, but you're telling me that they were all attributed or aligned in, by April 1st. So there's three quarters of a year of information there. Correct. All right. Thank you. So at some point in time, I understand kind of the different focus of the Medicare, current Medicare program in Vermont and this proposal before us, but I'm just wondering if the, if there has been any thought about aligning our all-pair model to, which we haven't executed yet, but everyone is hopeful in crossing their fingers that that will happen soon. With this, with this ACO, because it's, you know, we're a small state, the all-pair model is really important as kind of a blueprint or a template or a pathway forward. And I'm just wondering, but so we don't really know much about the Clover ACO and our all-pair model isn't resolved yet. And those seem to be two structural entities that at some point we've got to have alignment between the two. And I'm just wondering if any thought has been given to that at our staff level. Yeah. Tom, that's a great question. We've given it some thought. I'm sure others beside me will have thoughts on it. The two points that I included in the presentation, we kind of looked at some basic alignment questions. You know, we took a look at quality measure alignment and we took a look at scale. Now, again, it was, it was sort of an exercise to, you know, kind of get us started to scale this scale. The scale targets are waived for this year, but we wanted to take a look and see, you know, can this, since this model didn't exist when that agreement was negotiated, you know, what is it that we might want to understand as we go forward if we're going to have different types of ACOs operating in Vermont? So, you know, to start, we looked at scale and we looked at the quality measures. And I think that this is a, you know, the conversation that we'll want to keep thinking about as we go into those negotiations for the purposes of the budget review and approval. We didn't think, you know, we didn't have any recommendations on how it would be relevant here, but it is something that we are to keep an eye on as we go into those or continue those negotiations so that we can understand how this type of ACO arrangement might fit into our future agreement. Thank you, Marissa. So, I only have like two or three other quick questions here. I noticed it was in table three under quality measures and then there was this column called direct contracting and there were checkoffs on a lot of these measures. But one that wasn't checked was, it's on page 23, diabetes mellitus. I don't know if I pronounced that right, but that wasn't what was not checked. And in Vermont, diabetes is some pre-diabetes is, we're diabetes is a significant force in undermining the health of remoders. So I'm wondering how this ACO will engage with a pre-diabetes, maybe through clover assistant, I don't know, a pre-diabetes effort and obviously trying to avoid a diabetes consequence. So that's a question. That was on page 23. Get back to me later. I just saw that it was not checked. And I would think that'd be an important health risk to be engaged here. Let me see. And the only other thing I would echo is what Patrick profiled, the clover health investments fourth quarter in 2021 financials came out. At least they were on the web on February 23rd. So it's just a couple of weeks, a few weeks back. The stock over the past year has dropped from $8.12 a share to $3.09 a share. The net loss for the quarter was $187 million. And for the full year, $587.8 million. And the growth, as was said, is going forward. And the comments going forward is really aspirational growth around this ACO effort. And I'm just wondering if I should be looking at the glasses half full or half empty. And because the finances here are pretty much in the red. But the aspirations are hopeful. And I'm just wondering if there's any insight, additional insight into these financials that can profile the future for clover investments and clover partnership. So those are my areas of concern. Thank you very much. Thank you, Tom. Other members of the board with the comments or questions? Other members of the board with comments or questions? This is Robin. I don't have any questions. I thought it was a very thorough presentation. And Tom asked a lot of good questions. So I guess all I would say is I am interested in having a little more discussion around the quality reporting in terms of the fact that it's just one practice and wanting to make sure we have those beneficiary protections in place. That doesn't have to be today, but just wanted to raise that for others to think about. Kevin, I'll just jump in. I really appreciate that the thorough presentation and all the work that the team did, teams did in analyzing this. Two kind of just thoughts or questions, really. One was the provider network. I noted there was one, obviously there's one primary care practice. There's four or five SNFs. I can't remember how many. None of them being in Burlington. And so I was wondering, I assume that they're contracting with these skilled nursing facilities as preferred providers in order to support the primary care practice, but none of them being in Burlington. I'm wondering, are these all Genesis, skilled nursing facilities? What is the common theme here around those skilled nursing facilities? And are they close enough to the beneficiaries to be of help? Sorry, this is Dave. We're happy to, I don't want to jump in out of turn for if you all want to ask all your questions and then have Clover respond, but certainly Kevin and I can answer your questions as you have them if you prefer. So whatever you, whatever you like. Go ahead, Dave, answer the question. Okay, great. Yeah, yeah, sure. So Kevin, did you want to talk about the SNFs that we have? I can say, I don't know. We do have a contract with Genesis. It's likely that you recognize that. I don't know that those are specifically Genesis facilities, but we do have a contract with Genesis. And I know that we've been working with a number of other facilities. We just haven't gotten them to contract yet in Vermont. Okay. Thank you. The second question actually is probably not really for Clover, but it was interesting to me and I'm just, this is more to the team wondering if there's, I was intrigued by the ACO reach program and their new requirements around health equity and health equity benchmarks in particular. And I guess I, you know, it was going to say to the team, are there any learnings that we can take from those health equity benchmarks that are coming out of ACO reach and apply them to some of our regulatory processes or just be thinking about what are they measuring? How are they measuring it? Should we be learning from that? So just wanted to kind of throw that out there. It was intriguing to me and I'd like to hear more about it at some point, kind of unrelated to this, but this particular decision, but interesting nonetheless. But thank you very much to everybody and thank you to the Clover folks for answering my question. Thanks, Jess. So there are other comments or questions from the board. Thank you, Joe. This is Tom Walsh, Marissa and team. I just wanted to echo the others who thank you for all the work. This is a rapidly changing area and I appreciate the thoroughness of the work. Really the four things that I've tried to keep an eye on as we've been thinking about this particular case. The transparency with the CHP performance, particularly in Vermont, the way that Patrick described that, it's not easy to see what would be happening in our state. And so I think that that's important to keep an eye on. I think it's important to keep an eye on the, not just the quality of care that Vermonters are receiving, but actually their health status and their risk of greater illness or their risk of admission or what happens over time with that if we can keep an eye on it. The out-of-pocket expenses for Vermonters. In traditional Medicare, patients can go where they want. But in our discussion, we talk about preferred provider networks routinely. And so it gives me some pause to think about what may happen to the out-of-pocket expenses for Vermonters who seek care outside of the preferred networks. And then the fourth and last thing is really that I want to keep an eye on and appreciate the staff's help keeping an eye on is the alignment with our all-payer model 2.0. I'm still a little unclear on what happens with that. Organizations like Clover are growing rapidly. It's new to Vermont, but not new to the nation. And if similar growth happens within our state, what does that do to the plans we have for the next generation of the all-payer model? So those are my four areas. And I think I appreciate the thorough presentation. I think the ACO reach changes help with some of the areas of concern that I've brought up. So I really just want to say thank you to the staff for such a thorough job. Hey, if I could. I just want to address the preferred provider piece. Go ahead, Kevin. So I want to be clear that preferred provider is the terminology that CMS has used to define this class of provider. It does not prohibit a patient from seeing any provider that they choose. They still have, and there are very specific precautions that CMS has put in place, the patient still has the right to choose any approved Medicare provider that they want. And we can contract with a preferred provider, but we can't force a patient to see that preferred provider. If I could, sorry, go ahead. Let me interrupt you, please. No, that's my understanding to date. And that's just an area of concern that I think we want to pay attention to. So I appreciate that, Kevin. Yeah, and I was just going to piggyback that and say, in fact, the preferred provider network and that language has always been to me unfortunate, but it's not even the sort of, it's the participant providers that are the main providers and the ones that are actually most important to an ACO or a DCE anyway. And so the whole concept of a preferred provider is sort of bizarre anyway. And actually the thing that distinguishes the preferred providers is not something related to beneficiaries, but to those providers themselves because it gives them the opportunity to participate in multiple ACOs. They could participate with the Vermont All-Payer Model as well as with Clover Health or any other ACO. And so that was what was meant to distinguish them along with the fact that they're not used for alignment. And these may be things you know and I understand the idea of keeping an eye on it. So I'm not trying to be the dead horse here. And one thing I'll say is through ACO reach, through direct contract, and one thing that will always remain the same and has always been a non-starter as even back to my CMS days developing the models was the idea that patients are not going to have additional out-of-pocket expenses, that they will never be restricted in what providers they can go to. That is one of the key things that distinguishes the ACO models from Medicare Advantage is there's no prior authorization, medical necessity review, and those will never become part of the model. They're not now and will not become part of the model. Thank you, David. Is there other comment or questions from the board? Before I go to public comment, I'll ask the healthcare advocate if they have any questions or comments. Hi, Jermelyn. Excuse me. Good afternoon, everyone. Sorry, I'm kind of losing my voice. So I'll keep my comments brief. I just wanted to thank board staff for the opportunity to collaborate on the questions that were asked and just state that we agree with the recommendations that the board laid out for you today. So that's all we have. Thank you. Thank you, Sam. Okay, at this point, I'm going to open it up for public comment. Does any member of the public wish to offer comment at this time? And I'll go first to Walter Carpenter. Thanks, Kevin. I have a whole bevy of stuff here, but I'll just confine it to a few things. First of all, Tom Walsh was kind of thinking along the lines that I'm thinking of about patients and ironically, a healthcare system is about patients and this is about business. And one of the things I want to ask here is what is appropriate utilization as a Medicare recipient or someone who's on Medicare and as a patient, I'm curious about what appropriate utilization is and who determines that. And in a system that is rife with middle people, the direct contracting entities are just another middle layer. And the preferred provider network, which Tommy so nicely raised, was on my mind because having had to face network issues before, I can see where this is going to be a problem for patients. Plus, the direct contracting entity deciding which patients can go where, what is appropriate care, and so on and so on and so on. I mean, the incentive for value-based care is to essentially lower the... decrease access to care so that you make more money. And DCEs are about privatizing Medicare. So, I'm really nervous about this and the questions brought up about Clover's record with shareholders, their profits and losses are good ones and I backed those questions fully I don't think Clover should even be in Vermont, but that's another story. And I think they should be monitored extremely closely and regulated thoroughly. Thank you, Walter. We appreciate your comments. Next, I'll turn to David Ault. Thank you. I just wanted to also say what others have said about thank you to the board staff for all of their efforts. I know from emails and correspondence and from this presentation, how much time and effort they all put in to understand what Clover's doing and the changing intricacies of these models. I mean, I sit here with the 175-page RFA for the ACO reach and look at it 20 times a day. I'm still learning about it as I go through it. So, I really appreciate their efforts. And just wanted to comment sort of generally on a couple of things. I don't want to take too much of the board's time, but I did want to note that through this process, there was a comment from a staff member about perhaps not receiving all of the financials that would be helpful perhaps in an analysis. But I just want to make sure that we also make clear that it's been a goal of Clover from the beginning of this process to respond fully and completely to any questions that the board or the board staff has had. And after submitting our reporting requirements we did receive follow-up questions from the healthcare advocate, also the healthcare advocate from the board staff and have had calls and responses to address those questions and to provide clarity wherever possible. And so I just want for those on the call who are not familiar with that process to know that that has been going on as well. And also just the ACO reach changes obviously have come about for many reasons. I personally think that the vast majority of them are a reflection of the administration change and we were going to see regardless. There's also been opposition to direct contracting over a number of months. And I think Senator Warren and Rep Jaiapal and others have expressed some of these concerns. And so I think what's really cool about ACO reach is and shouldn't be lost and this was mentioned is the really like the double down recommitment of this ACO model to making sure that it is provider led for the patients with patient input. And it's not a minor thing to go from 25% governing body representation by the participant providers up to 75% and changing that there have to be two separate voting members for a consumer advocate and a beneficiary representative on the governing body as well. And so I think that's a really positive change. I think it's great to see. And I just want to highlight that piece of it as well in addition to the other protections that the team went through to do what everybody wants to do which is to make sure that the this risk adjustment model that CMS has been using and continues to use which everybody knows is imperfect is constrained to the best of its abilities while CMS and others continue to try to come up with a better alternative which just hasn't been hasn't been found yet. So I'll pause there. I know that Kevin is, you know as the guru on all of this for Clover, happy to answer more specific questions if anybody has them as well. But I would just say my final thought is that in hearing the presentation and in thinking about the ACOs and in particular about Clover's presence in Vermont just the idea of seeing the care that is being provided and it's not just about oh there's this Clover assistant tool that they use to help with the processes. Yes they do and it's a great tool but it's also the the ability to the care coordination which is involved and the ability to help patients not have to be in hospitals for three days that would otherwise have to be and can just go to in-home care or sniff care instead. And so I mean there's a lot of positive that comes for Vermonters through the ACO models as you know with the Vermont model and so that's why Clover is excited to be in Vermont and to keep working with patients and providers. In terms of the specific recommendations I think it's my understanding that the board is not taking a vote today. I'll certainly regroup with Kevin and the Clover team on their recommendations and obviously we can provide any feedback through the appropriate channels on those particular recommendations so I won't comment on them today but but appreciate seeing them and hearing the thoughts on them as well. Thank you David, appreciate that. Is there other public comment? Is there other public comment? Hearing none I'm going to turn the meeting and we're going to transition over a discussion on hospital budget guidance for the coming hospital fiscal year and thank you to everyone for the hard work on the Clover presentation and at this point I'm going to turn the meeting over to Patrick Aroni. Patrick. Thank you Mr. Check. I'm going to get my screen set up. Please let me know if we can. All right, great. Now good afternoon board members members of the public and other stakeholders. We're here today to kick off the first of potentially three weeks of discussions around the fiscal year 2023 hospital budget guidance. I'm going to try to navigate using this split screen look last year. I did an awful lot of modeling back and forth back and forth which is not the most efficient way to try to run through this and so I'm going to make an effort to keep the presentation up on the left hand side of the screen the entire time and then shift back and forth between the actual guidance document and the supporting appendices as we navigate through the presentation. So what you can expect today is a review of the changes that we've made through budget guidance and that is in line with the way we've done things in prior years. We're not going to go through all 14 pages verbatim. We'll just focus on highlighting some of the changes that have occurred, but also that we have a more integrated approach this year bringing folks in from some of the other teams to apply their skill to this process to better inform you in your decision making as we head into the actual budget process in the summer and early fall later this year. So you can expect to hear from those folks on the particular sections that they've contributed to and please direct your questions post presentation to those folks as well. Now we're going to get started here with the presentation of brief overview of the next couple of weeks. So here we are, week one, we're going to do an overview, review the appendices and draft budget for some of those changes. We will take board member feedback in the interim and go back to work and make any adjustments using that feedback that the board would like us to make including contributions from the HCA and I will continue to underline that through this. History has been that the HCA usually contributes to the process once they've received the initial draft of the guidance and get a full view of what's changing in this year. And so we've delivered those documents to the HCA for their contributions hopefully by next week in which we will review that and any other changes that have occurred in the interim and we have the ability to potentially get a vote through on guidance next week should the board be satisfied with the changes that are made. If we cannot reach a conclusive decision next week then that would take us into the meeting on March 30th in which we would do a final review and get to a vote by the board at that time. And that all leads into the staff delivering to the state's 14 community hospitals a final guidance on March 31st and then that will take us as you can see on the screen to the left here through the next several months as hospitals begin to prepare and finalize their budgets for submission on the first meeting. And then we get into a flurry of activity in late July where we present the initial submissions to the board giving you a first view of what the system and each individual hospital has proposed and then we move into the weeks of hearings on at the beginning of on Monday the 15th and Monday the 22nd and then we get into our deliberative sessions for two weeks in September ending with the 15th where we finalized and after that the staff will work with our council to draft budget orders and get those to the hospitals by October 1st. So a brief overview of priorities process and outcome again very similar to last year hospital financial health and environmental challenges that are being experienced are a priority for this process. Ongoing regulatory alignment you heard me talk about the integrated team effort data driven analysis and decisions we're beginning to incorporate more of that into the work as well as you will hear throughout this presentation and then reasonable schedules and turnaround times and I will build upon that as we move through this through the process it was a collaborative effort across GMCB teams and as the board chair mentioned will be opening public comments until Monday the 21st for this initial stage of the budget guidance discussion and the outcome here is to prepare a final draft of the budget guidance with continued alignment of narrative and presentation and updated appendices to support that narrative and presentation as well. So this year to really level set and really tie some of the challenges that exist in our space our shared space with the hospitals is a review of some of the items from last week for the system as you heard me mention last week if you were on our presentation this is a very difficult time for hospitals to budget for hospitals to operate and for board members to regulate given the fluctuations and volatility that currently exist with the ebbs and flows of the public health crisis and so providing kind of a level set and recapture of where things have been we know the system had a significant downturn in 2020 with a rebound in 2021 but it didn't quite reach its budgeted expectations on the whole and then we have approved budgets for 2022 that are heading towards the three billion dollar net patient revenue mark it is yet to be seen as early on as we are here not even six months into their fiscal year if that is something that is going to be achievable this year as we know it's been a very long few months to start off their fiscal year and of course those decisions that were finalized last year do exceed that 3.5% trend rate for the system that we set coming off of 2019 and to continue in that space especially as we get into an MPI recommendation by staff in discussion by the board you can see here the history going back over the last five years that the board has set a budget growth ceiling although the system wasn't meeting that from 17 to 18 it was relatively consistent in its system-wide performance and then of course we have the twin pandemic years here with results being extremely mixed based on the circumstances that have occurred in each one of those fiscal year cycles and finally a little more granularity on the net patient revenue piece we can see here that the results on hospital by hospital basis have been extremely different but overall pretty much reflect for the most part each one of those years and the changes that exist within and so that leaves us in a space where 2022 is still uncertain and there's going to be ripple effects no doubt that take us into the 2023 fiscal year that we're discussing here today and to highlight it and capture everything is that although we have that fluctuation in that patient revenues that ebbs and flows with the pandemic and the circumstances and the one thing that is not fluctuated that much is operating expenses they remain consistently on the rise and as you heard us discuss last week and board members discussed as well there are certainly going to be further challenges in that space throughout this current fiscal year looking into 2023 so we wanted to provide some look back context there just to underline that and really level set for the discussion that we're going to have over the next couple of weeks so now I'm going to move into the guidance document on the right hand side of the screen I'm going to touch on some minor issues before we start getting into some of the changes and additions that we've made and I'll start with the timeline here to help with some flexibility a minor narrative change here around the August 1st capital expenditure sheets and adaptive we just added not later than that. That way hospitals can feel comfortable that if they want to submit it all on July 1st they may we initially push that back a month to allow them to focus on the operational components of their budget and getting that in so that we can get that piece moving and so we know that some hospitals enjoy putting everything in on July 1st some prefer a couple of weeks of flexibility some take the full month that's entirely fine but setting that expectation that August 1st is the date because we need to begin to prepare materials for our board members moving down to the deliberations periods the 1st of the 15th we do have a note here that the board will deliberate in order of budget hearings this is from some feedback that received from hospitals last year that they weren't sure when the board was going to deliberate on their specific hospital that was great feedback and so last week Cara Crice our administrative assistant sent out the hospital budget hearing schedule and so hospitals can expect boards to deliberate in the order in which you present the only caveat to that is if there is outstanding material items that the board has requested and need to make a decision on we will bump you from that space in deliberations as we await those follow-up items also it does not guarantee the board will make a decision during that deliberation however it's been my experience that the vast majority of time as the board deliberates they ultimately arrive at a decision in the same day so a small change hopefully that helps our hospitals plan as we look several months out around vacations I'm often also preparation for those budget hearings moving down on to page 5 here this is a space in the net patient revenue part of the guidance that will remain blank until the board reaches their final decision and then we will populate the date and the percentage growth should the board choose to make a decision in that space but that is something that we'll see week over week as we begin to migrate our way towards a decision on overall budget guidance and potentially net patient revenue fixed perspective payment growth moving down into the factors considered during review our legal team has put forth a few other criteria factors that the board may use and you're going to get a clear understanding of why these exist as members of our team begin to discuss some of the additions later on but the majority of these exist around some of the data monitoring component that we've built in this year this is something we discussed in our January 26th preview for the board so this is giving you the capacity to consider some of those factors in the decisions that you will make later on this year and in addition to that underlining some of the volatility in the healthcare finance space and healthcare operational space is the hospital's extraordinary labor costs and investments in labor as well as impact of those costs and investments on the affordability of healthcare and that is tied back to House Bill 654 which has made its way through the legislature allowing the board to consider those extraordinary factors in their review of hospital budgets for fiscal year 2023 moving down into the narrative section you'll note that as we get into this section that the presentation on the left identifies each section in which there will be highlights and therefore have been changes so here we are in narrative section A executive summary you can see on the left hand side that we are tying it to that so one of the requests from the board was that we add some narrative here to capture sustainability planning at the hospital we've left it fairly broad in this executive summary space for a few reasons one funding for sustainability planning is actively moving through the legislature as we speak so there is still a level of uncertainty there in that space however as the strategic leadership of these hospitals will be effectively signing off on these budgets and presenting these budgets we felt it was important that we bring this in as part of the executive summary because certainly this pandemic is continuing to teach some lessons about sustainability of the healthcare environment and we look forward to hearing from hospital leadership on what some of those lessons are and potentially what some of the strategic vision is in helping bring about a more sustainable healthcare space for their institution so we've left that relatively high level of course these are changes that the staff has put in here and once we get to recommendations we'll talk about the board's ability to accept, reject or alter those as they see fit so we'll continue to move through the presentation here our next stop is going to be narrative section B subsection 3 which is charge request and you can see here in the subsection subsection D that we're looking to follow up on results of the hospital's approved change in charge for fiscal year 22 this has been in discussion for a couple of years now with some board members and so we thought we would propose this as part of an addition here so this section will capture what the hospital is asking for in sub sections A, B and C and some of the detail that comes along with that but also allow us to understand some of the results of the approved change in charge for fiscal year 22 we read in at least one of the narratives in 21 that hospital has effectively reduced its cost on certain services and therefore has been able to reduce its charges and that would be good information for the board to have as it relates to what was approved last year we've had another hospital at the outside of the year who said we've had certain volume conditions that have changed these assumptions were very very different for our budget therefore we reserve the right to go the full amount but we're not going to right now and also the results of some of the negotiations with commercial payers are important to to understand yes we may have approved you for a hypothetical 4% did you actually get approved for that so the hospitals can so that the board can get a better idea of the request this year and what they the hospital received and employed in their finances for the year prior to that the next stop we are going to section C this is another piece that will be proposed in our January 6th presentation as the pandemic has opened a lot of fissures around access to care and equity and equitable access to care so we wanted to pose a question to the hospitals about what their hospital is doing to recognize and correct inequities in their community and prepare for the development of health equity measures we know that CMS is moving in this space and we just heard that health equity is going to be a part of this new model this reach model in our prior discussion here with clover and so health equity is really taking is really being spearheaded by several components of our health care system and we want to start to understand what our hospitals are doing in that space by calling that out directly as part of this budget process moving on we're going to come into the conversation space and some reimagining of the questions and approach around this particular space and its contribution to this process and this is where we begin to integrate our team members from other components of the GreenMap Care Wars regulatory process and having them apply their knowledge base to the hospital budget process in general and our point person there has been Michelle Sawyer who's been working in this space back and forth with her team in crafting some of these questions so I'm going to turn it over to Michelle to walk you through these items and some of the logic that she's using to arrive here so Michelle I'll turn it over to you. Thank you Patrick. So most hospitals in Vermont are participating in value based care arrangements and these questions serve the purpose of hearing about that experience from the hospital's perspective and how it's impacting their operations, priorities, and delivery of care. It's also an ongoing effort of the board to align regulatory processes whenever possible. The board has been given the authority of ACO oversight and these questions serve to better integrate that authority with that of the hospital budget process. So the first question referencing the data submitted in Appendix 5 if there are any value based care programs that the hospital is not participating in for calendar year 2023 please explain why and describe any barriers that exist. What changes if any to these programs would need to be made in order to facilitate your participation. So Appendix 5 just refers to a very simple table as part of the workbook in which the hospitals list out the arrangements that they have with one care by payer. So the following questions assume that the hospital answering them is participating in at least one of these payer programs. The second question understanding that the pandemic has just started to recede. What changes in each of the hospital's cost centers that relate to value based care initiatives such as population health management, care coordination, chronic condition management, etc. What changes to those cost centers have been made as a result of participating in the ACO? Be specific in describing each cost center and how it has changed since joining the ACO. Additionally, speak to how the fixed payments or other ACO pavements from one care Vermont are or are not advancing value based care at your hospital. The third question as three parts a as the pandemic recedes what specific population health priorities are emerging for the hospital. Obviously we know where all nearly all of efforts have been focused but we're hoping that as things are starting to shift that maybe some energy can be put towards other priorities. B, how will each of these priorities be conveyed to providers in order to impact care delivery? How will success be measured for each of these initiatives? The fourth question as of calendar year 2022 one care Vermont is providing each hospital's HSA with quarterly quality reports. How are the results of these reports being communicated to providers in a way that will impact care delivery and quality outcomes? And the final question is two parts regarding the calendar year 2020 settlement information from the hospital which will be provided in some tables. What are the planned investments of those dollars in furthering the hospital's health care reform goals? And if no investments in health care reform were made with these dollars how are they invested? And then the second part of this question takes into consideration the fact that while all of the hospitals did receive a settlement in calendar year 2020 not all of the hospitals experienced a net shared savings. So some experienced a shared loss during this time period. So that that second question asks if they experienced a net shared loss how is the hospital using that information to inform change to their delivery system? And that is that is the value based care participation questions. So Patrick, I'll turn it back over to you. Thank you, Michelle. Very thorough. So the next stop here on the guidance document and some of the changes is around supplemental data monitoring which is a direct connection to some of the work that has been done in the sustainability space. And to speak about this I'm going to turn it over to Jeff from our analytics team. Jeff, the floor is yours. Thanks Patrick. So jumping right in section G will delve into the relationship between a hospital's budget and some of those things under the hood. For example the characteristics of their communities especially how they've evolved over the past decade or so as well as the choices and characteristics of their peer hospitals throughout the state of Vermont. It's broken into three sections so if you go to section one there the market share report we're going to take key service lines and look at the changes in charge and discharge migration over time to see which hospitals have been growing which service lines which have shrunk and where patients might be migrating over time. It's very similar to the patient migration and patient origin dashboard it's currently published on the website. For section two summarizing that it's going to be very similar to the burns HMA work looking at how reimbursement and costs vary across the hospitals and service lines. Hospitals will be asked to explain the outliers in their performance compared to other hospitals the question still being ironed out here. And section three will be the demographic report just a quick and easy tables and visuals of how certain populations have changed in each health service area over time and how that might affect the bottom line of hospitals moving forward. The hospitals will receive uniform data sheets in June will be generating much of this data ourselves and they'll only be asked to respond to a certain list of questions the examples being right here ease and efficiency are at the top of our minds and we hope to hone this particular part of the budget guidance to serve that. So I will pass it back to Patrick Jeff and Jeff highlighted some very important questions. This is data that's being generated by the staff. All we are asking is that hospitals help us understand the results of this as it relates to their specific organization and build that out in their narrative. And as Jeff noted very important will provide these reports by June of 2022 so that can be incorporated into the narrative. Moving ahead here one last item the actual guidance document is that we have removed the hospital budget hearing exemption criteria that is the result of discussions that we've had with board members over the last week and I think the information we presented last week and some of the volatility that continues to exist in the space has the board wanting to hear from each individual hospital especially as things continue to evolve over the next few months as they have over the last few months. So we have removed that that will be part of our recommendation here and to just fill out the guidance here we have built out in the presentation as we seek to keep the narrative and the presentation flowing together we've just built in the equity and supplemental data monitoring pieces as those are two entirely new components to this so that rounds out the actual budget guidance document. I'm going to next move to the appendices changes here are relatively limited and we heard Michelle talk about some of that one of them is the inflation table. We have added an example down here from a hospital that populated it last year however as we get into the board discussion board member Holmes pointed out to me that this was not properly filled out and so I think that leads us to needing a little bit more explicit instruction to make sure that we have a consistent population of this data here and that it's done correctly by hospitals so our intent here is to provide an example this will change based on some of the discussion that we have once the board members are sharing their comments next up is appendix five this is what Michelle spoke about we broken out here by payer if the hospital can provide that information from Blue Cross and MVP we did leave the commercial space open if this is not possible or if there are potentially other commercial payers that exist outside of the MVP and Blue Cross space the excuse me the COVID-19 advances and relief funding we've removed some of the past description so please add the source they have of course changed over time we've had ARPA we have some of the more recent funding sources that have come through we've eliminated fiscal year 20 that's kind of old news now and so we've built in a similar three-year look to the past where please provide us updated September 30th 2021 figures now that your year is final activity in 2022 and you'll notice that just as we did last year we removed amounts received we don't want to pretend like more money is on the way if it's not however recognizing in revenues or recorded as liability is money that was received in 2022 and perhaps has not yet been pushed through the income statement for fiscal year 22 as of when the budgets are received so we just reconfigured this to update it for 2023 as we continue to look forward in that direction and finally we removed the COVID vaccine tab last year we allowed for adjustments to net patient revenues and operating expenses that had to do with the mass vaccination effort that the hospitals were undertaking about a year ago we understood at that time that would most likely be a one-time effort and then after that things would move into the direction that they have where we simply go and receive any booster shots that we may need to come up so that mass vaccination effort is no longer in play so we've removed that tab from the appendices so as we continue to migrate through the discussion here I will put the guidance document back up here as we continue to migrate through the discussion we do need to discuss NPR for 2023 also a point for discussion that we'd like to hear from the board is how would the Green Mountain Care Board like to continue access to care wait times monitoring in the 2023 process primarily the results coming from the wait times task force was that monitoring should continue but also we know from that effort that the measurement we've been using third next available appointment is not a great measurement by which to monitor and so we're hoping we can receive some guidance in that space to include in this year's budget guidance so that we can continue to do our diligence in that space and then highlighting and I'll continue to do this that the HCA has yet to contribute to the guidance and I want to make sure we carve out a space for them in the coming week to offer up their contributions to the fiscal year 2023 guidance so with that we have a little bit of work here to do with hospital budget policies including some potential changes to the budget amendments and adjustments policy and I'm going to turn it over to our staff attorney Russ McCracken to walk the board through that Russ great thanks Patrick I will I think I can just speak to this it's fairly straightforward I'm going to start with the policy on hospital budget enforcement last year as you probably remember the board adopted a standing policy so it would be effective from March 31st 2021 forward we're not recommending any changes to that at this time so we're not recommending any board action it would simply be the same enforcement policy that was put in place last year carrying forward through this year secondly accompanying the guidance every year is a policy on budget amendments and adjustments this covers mid-year adjustments that might be made for accounting purposes provider transfers other unexpected changes in the hospital's budget and includes requested mid-year amendments and for any requested mid-year amendment the policy has a a list of steps that the hospital would follow sending a formal letter of request to the board requesting the change some information that that letter has to include and our recommendation is to add to that policy that if a hospital is requesting a rate increase it must notify the applicable commercial insurers of the requested rate increase to the board taking action on the requested increase that is a suggestion that we recommend adding to the steps for hospitals requesting mid-year budget amendments and I'll make sure that both of these policies are included with the primary hospital guidance document here on the website and circulated to the board and that was all I had so back to you Patrick thank you Russ so as I alluded to we do want to discuss the recommended Fiscal Year 23 NPR-FPP growth ceiling and doing so we're attempting to capture some of the fluctuating activity that has occurred in the healthcare finance space and so to talk through the next couple of slides I'm going to turn it over to one of the newer members of our finance team Matt Sutter to walk us through some of the information we have up on the screen Matt everyone thank you so as Patrick said, given the uncertainties surrounding the pandemic and kind of general economic conditions we wanted to look at recent inflationary trends as kind of a guide for recommending reasonable growth target so we looked at a couple of different indices we looked at producer price index for medical care services reflected in the green and then consumer price index for healthcare services in the blue so each of those bars on the graph represents a six month period and the reason we look at that is because the way it's presented we get monthly inflationary data and if you just graft it out it looks wild so we're trying to smooth out some of the variances you see month to month and get probably a better grasp at least for our purposes of understanding sort of broader trends without going into discussing each number as you can see the red line here represents the start of COVID and you can see with green especially the producer price index that increasing significantly relative to prior year periods before COVID interestingly COVID kind of resulted it looks like a little bit of a drop in consumer price index at least at the outset and especially in some of those periods like for example last summer I guess the numbers are kind of small but I think it's through March through last August you're seeing kind of a drop lower than average inflation only to spike again and so I can't describe I can guess at why that is but my hunch is it has something to do with vaccinations around that period economy kind of starting to look like it was rebounding and things getting back to normal but as you can see 2% spike in both CPI and PPI over the last six months is concerning I think you can go to the next one I'll set there so on this one the table on the left is basically just showing in a table format the same data from the chart on the previous slide to kind of develop some kind of projection just took looking at the last six months and kind of knowing the environment the world's in right now fuel prices etc sticking with that kind of 2% six month inflation period for our the red projected periods seem kind of like a safe number to go with and so our methodology here was to look at pre-COVID inflation in those tables on the right pre-COVID inflation averaging about a percent every six month jumping to about 1.6% in the periods after COVID started which reflects about a 61% increase in terms of just inflationary pressures above the normal and the table below is for the projected inflation is just including those red lines so those two six month periods we're projecting out to percentage inflation and if you include that then we're looking at about a 75% increase over where we typically are in terms of producer price index inflation and so trying to come up with a methodology of at least offering a recommendation for NPR growth decided to take 3.5% that we normally have in a typical or we've had typically pre-COVID say 1% every six month inflationary environment and saying hey if inflation is up we're seeing inflationary pressures up 75% over the typical let's recommend 75% above our 3.5% which gets us to about 6.1 and that's the methodology there I can let Patrick fill in additional details but we'll discuss that on the next slide yes thank you Matt so that's our approach to trying to get to a recommendation we do acknowledge that in this environment it could probably be just about anything right now however we wanted to use some of these indices to help guide our recommendation to some extent we understand that looking forward is very very difficult about that ad nauseam but from what we're seeing here is that the COVID world has seen growth at levels that we were not experiencing prior to that and we factor that in and say well you know what as things stand today if they stand as they are we can expect those levels moving forward but then again nobody really knows so that's the approach that we took in regard to an NPR figure so wrapping up here with staff recommendation we do recommend that the board establish an NPR growth ceiling figure and our recommendation to you to accept, reject or alter is the 6.1% with the factors that Matt cited on the previous slide and that is tied to some of the figures that we have the most recent figures that we have in those consumer and producer price indices data we don't recommend any guidance on average change in charge for fiscal year 23 due to the unprecedented rapidly changing environmental factors and challenges that our hospitals are experiencing we do recommend the elimination of budget hearing exemptions for the reasons discussed we also recommend the addition of sustainability planning discussion component to narrative section A and we also recommend the addition of the change in charge results questions outlined in narrative section B relating to the hospitals fiscal year 2022 green mountain care board approved rates and also we recommend the addition of health equity question in section C of the narrative migrating down the list here we also recommend the addition of the reimagined value based care participation questions and section E of the narrative and the addition of the supplemental data monitoring pilot reports in section F again those reports are due to the hospitals in June of 2022 we also recommend continued deferment of the quality budgetary component until the collaboration with VPQHC quality task force results become available last I was aware those were due sometime in August of 2022 however the reason we're recommending this is that this is tied directly to sustainability I've taken part in a couple of those meetings in an observance capacity with Michelle degree and board member Walsh and there's a solid group of folks and stakeholders involved in that and the hope is that that work will produce some meaningful quality insights that we can use in our processes moving forward so we feel that that's the best space for that work to occur which is out of course outside of this process here we also recommend the updates of the budget amendment adjustment policy that Russ walked us through and finally here at the end continued discussion on the approach for monitoring of wait times and what the board would like to see in that space and how we can go about that and also again highlighting and underlining that the HCA contribution is not yet part of this discussion and we would need that prior to a vote that brings us to the end of the staff presentation here and of course wrapping back to the beginning of the discussion after this meeting today we would move towards the March 23rd meeting make adjustments to the guidance here and have the opportunity potentially to have a final vote and if that does not occur then further adjustments after that meeting moving toward the 30th and getting to that final vote space so with that Mr. Chair I will turn it back to you for board comment and feedback thank you very much Patrick I'll open it up now for board comment or feedback who would like to start I can start thank you to Patrick and the team for your presentation and walking us through proposed changes I did have a couple of questions and comments on the guidance document itself the first is in section 1 which is the bottom of page 4 of the guidance which indicates that we will review and evaluate the submission in the context of the actual 21 and projected 22 and challenges presented by COVID one of the things that I thought was super helpful last year given that we know 2020 was low and 2021 had its own challenges and now 2022 is having get more challenges it was helpful to me to go back to 2019 so that we can kind of get a sense of kind of where we were so I'm and this maybe isn't more of a question for legal to ponder but I wonder if we need to be more explicit that we actually may want to go back further than 2021 when evaluating the budget submission so that nobody needs to respond to that now I just wanted to throw that out there because I think because of the COVID challenges it is tough to not take any even broader sort of historical view I also had a comment on the hospital planning I would like to see more specific language there we've been working on sustainability planning for quite a long time now with of course a pause due to COVID and some change in approach because we wanted to take some burden off of the hospitals but I I would be very interested in understanding from each hospital how they're looking forward to potentially engaging in the sustainability planning as we move forward so if the resources in the budget in S-285 are passed I do think we've committed should we get those funds to a significant process and there was a discussion about providing opportunities at all stages of process for meaningful participation and I think given that hospitals will be submitting their budget not too long after the session that hospitals need to be thinking about how they would be able to meaningfully participate do they have resources set aside how are they thinking about that on their end so obviously we're not going to know by the end of the month the money but given that sustainability started as long ago as 2019 and way back when we were doing the rural health services task force I don't think even if we don't get the money that we can stop looking at those issues we just wouldn't have the resources to do as thorough a process so maybe that's something the team can put their heads together on in the guidance and then I think I had one other so and I had one other question which is maybe a question for Vaz or some of the stakeholders to think about and provide public comment on in the healthcare reform value-based care participation excuse me and E which is on page 10 I'm wondering if the term cost center has a meaning and is the right terminology in the question E little I to double I you know because certainly the blueprint brings certain resources to communities and the hospitals work collaboratively with the blueprint community health teams they often host in most of the counties they host those teams so I want to make sure they're thinking about this question broadly and not just in a financial way so I don't know if it's operations or some other term but I'd love to hear some feedback on how people interpret that and whether we have that question worded in a way that makes sense to the people answering it in terms of the NPR FPP recommendation I think it's useful to look at the inflationary measures that are specific to healthcare but I also think it's useful to look at inflationary measures that are applicable to consumers and Vermonters who then have to pay the bill so I'm wondering if we could also take a look from that perspective and then my other question related to that is NPR is of course price and utilization so how do we think about that when we're looking at the various economic measures and then lastly this is a significant departure from the total cost of care trends that we've committed to in the all pair model agreement between 3.5 and 4.3 percent so this may not be possible but I'm wondering if we could reach out to Sarah Linnberg and see if we can get a sense of how this would impact our performance under the agreement in the future as a point of reference now obviously that's we're in extraordinary circumstances there's you know the cost we certainly have heard a lot about cost of travelers and workforce pressures and those absolutely need to be taken into consideration but I think I need to see the whole picture to understand how the decision will impact all different parts of the system and those are my comments and thoughts. Thank you Robin are there other comments or questions from board members? Sure I'm happy to go. Thank you so I guess I'll go actually in order of my notes which may or may not be helpful to everybody else's order but one was I started with one of your last questions which was around wait times and so I think it's really important to build on the learnings from the wait times investigation I think understanding wait times is going to be critical I know there was a recommendation for the Department of Financial Regulation to be monitoring wait times going forward and they are seeking statutory authority to do that but that will take time and may not even happen in this legislative session so I think that it's the onus is on us to at least understand what's happening in wait times in our hospitals that we regulate as you said Patrick the third next available appointment is not we've learned through that process that it's not a great measure of the patient's actual experience in trying to access care. There's two components to wait times one I'm going to call the referral lag the referral lag is the time between when for example a primary care provider this is in specialty care primary care provider makes a referral and when that appointment is scheduled and in some instances that can take weeks unfortunately and then there's the visit lag which is the time between when an appointment is scheduled and the actual visit date and that can take months and so one of the recommendations that I'll throw out there for a way for us to measure better measure wait times and those two components the referral lag and the visit lag would be for asking hospitals for all of their practices primary care and their specialty care practices and I wouldn't define what those specialty care practices are I would just say for all of your primary care practices and specialty practices because I think last year we missed some of the specialties that some hospitals had in the form that we put out there but I would also add imaging in there because I think that's an area where we saw that there was significant wait times in some areas of the state so I think for all practices primary care specialty care and imaging a way to get at referral lag would be the percentage of appointments that are scheduled within two days and again that's when when a referral was submitted to when the appointment is scheduled and then for the visit lag I would suggest percentage of new patients seen within two weeks one month three months and six months and the reason to focus on new patients I think is because I think repeat patients or current patients may have different lags different experiences gaining appointments I think it's probably onerous to ask hospitals to give us new and existing patient information for all of those I think new patient appointments will be a good proxy for what the wait time experience is just using percentage of patients within two weeks doesn't really get us the tail how many patients are waiting a really long time so by getting two weeks one month three month and six months you start to get an understanding of the distribution of wait times across patients so that's what I'll throw out there as a possibility for really getting a better sense of wait times just in my notes here workforce is such a significant issue we've been hearing about it from from hospitals from other you know providers outside of the hospital systems we know that there's a significant shortage and in issues we know the expense of travelers so I think it would be helpful to have just a couple of questions around workforce that are specific to workforce one would be I'd really like to understand the percentage of their nursing staff that are that are travelers and what they're projecting as travelers we often get that information from them I think but having it be a specific aspect of this question I think also recruitment and retention we know is a really costly to an organization so I think it would be helpful to understand turnover rates turnover rates for MDs and turnover rates for the nursing staff to better understand what is happening with with that and that will be a good indicator of the recruitment and retention efforts that have to be done and then just an effort you know understanding the efforts to try and reduce shortages or reduce the workforce pressures I think would be helpful to understand I think there's some hospitals that are doing some really innovative things to try and increase the pipeline and I think it would be helpful for us to learn what those innovative solutions are and to the degree that some of those opportunities could be you know shared across other hospitals that would be useful to know so that would those are kind of two of the areas that I know that wasn't in the guidance already but might be added I think all right well let me just start with as I'm going through the document that patient revenue is one of the first features of you know with the double X's that we have here we're going to fill that in so I'm just going to share what I shared earlier in January I think that setting NPR growth rates has always been a really blunt instrument but I think it's blunt really blunt this year more than ever we as you said you know we have tremendous uncertainty this year budget planning is going to be very challenging we don't know what inflation is we don't know what utilization is going to be you know some hospitals may have built pent up demand in their budgets for this year in which case you know volumes may fall if that pent up demand was met or populations decline in certain areas that may be you know it may see decreases in volumes next year but we may also see you know other hospitals that were more conservative in their estimates of what happened what was going to happen to utilization this year maybe seeing a spike so I just feel like we don't really know but the hospitals do the hospitals have a better sense of what that utilization might look like based on what they put in their budgets this year and what they're seeing in real time inflation I appreciate the effort here to try and use some economic data to predict inflation for next year I think the way this the approach here in some sense assumes that the change in inflation pre-COVID to post-COVID is going to remain the same going out a little bit during this call the Federal Reserve has increased the interest rate by 25 basis points for the first time since 2018 and they're projecting numerous more increases in the interest rate which should have an impact they're projecting inflation to come down next year from this year so again I feel like it's going to be very hard to set an NPR growth rate that makes sense for every single hospital having a blanket NPR growth rate that's going to make sense for every single hospital I don't think is the appropriate approach this year so my sense would be to allow hospitals to submit the budgets that they think that they need based on what they're seeing in their hospital and then we evaluate as we always do on a case-by-case basis what we think makes sense given all of the information that we're going to be taking in and their estimates so that's kind of where I still fall with that although I really appreciate the effort to try and put some numbers around what might be expected I really like the section on the factors to be considered during the review I think that's really helpful I would add under the population or demographic data I would add patient migration data the market share data that is referenced later on I think just specifically calling that out would be helpful I also would cross off hospital reimbursement variation data cost and cost coverage is great I would cross off the from hospital sustainability because I think we you know hopefully that data is going to be updated the hospital sustainability efforts were from 2019 so I think that the analytics team is going to be updating it I guess I wouldn't tie it to hospital sustainability I think it you know going forward we should always be looking at hospital reimbursement cost and cost coverage data so I guess I would just strike the hospital sustainability part of that phrase I agree with Robin on sustainability planning and I like that suggestion under the executive summary section I would actually also like to add in that executive summary where you say including any information the GMCB should know about programmatic changes such as staffing and operational changes I'd like to be explicit there and ask for any service line changes if a hospital is divesting or adding a service I think that would be helpful to know right up front so I would just be explicit about that there and let me see in the charge request we can talk about that table if you want in a second but under where it says describe how the charge request affects the area of service for example inpatient, outpatient etc I guess I would just say let's be explicit it should be definitely inpatient, outpatient and professional I think we want to know how that charge request will translate to each of those three areas and then similarly under D in terms of giving updates to the board about approved change of charge I would like to see those updates by inpatient, outpatient and professional so we know what happened within each of those three categories of charge under operating margin and total margin under part B I like this question around how the hospital's budget might support or need to support other entities outside of the physical hospital we can maybe be a little bit more explicit if so please quantify the subsidy and provide information about the financial performance of the subsidiary sorry subsidy and subsidiary and I wondered if in equity whether health equity measures needed some clarification so I don't know if that's too general or if there's any way to define what we mean by health equity measures this is why I was a little bit curious about from the Clover presentation about health equity benchmarks how are we measuring health equity so I wondered what that might look like and sorry I'm going to keep going but you all can stop me if you have any if I'm not making sense in the supplemental data monitoring I was curious about what the key service lines would be how that was going to be determined and I was really happy to hear from Jeff about the patient migration because I was going to suggest that we actually pull in that patient migration data specifically to find out what percentage of residents in a community are seeking care in their home hospital if not where are they seeking care being very specific about trying to understand that it sounds like that's already in I but I just wanted to make sure that that was the case and then if you I can stop there that's a lot I know I can stop there if anybody needs clarification on anything I said and then I was just going to suggest we go to that one inflation slide Patrick does that what I said make sense or should I clarify any of what I said I think I've got it all and we can follow up with you offline if we have clarifications great. So I guess what I just wanted to point out about this table here is so if you look at the first line there's a 2% increase in wages it's a $500,000 increase but it's a 2% increase on wages and wages as a part of the operating expense budget is 60% I think that's right it's waiting that 2% over a very large proportion of the expense budget I think the percentages that fall below that line from this example those percentages were calculated on the $9,000,000 increase so for example if you take the you know $1,000,000 for contract staffing that's 11% that 11% is not the percent of their overall expense budget it's their percent of you know it's 1 million over the 9 million so the way that this was calculated is not actually matching what the example is on the top you're not we're not asking for the percentage the category percentage of the increase the dollar increase in expenses we're looking for the category percentage of the total operating expense budget right so you can see for example like the $500,000 is a very small component of say that 9 million it's not you know 60% it's not going to be we're not looking for what is the dollar increase and the percentage of that dollar increase we're looking for a way to weight each of the percentage increases in category by the weight you know by the percentage I'm not sure if I'm making my sense here clear to my I'm not making myself clear here but that category should be the percent of the total operating expense budget not the delta on how much their expenses have grown does that make sense Patrick and others on the team so I just I think we can give an example that makes that clear and I'm happy to help sorry I was on mute yes that makes sense and I will reach out to you after the meeting today okay great thank you that is all I have but feel free to if anything didn't make sense I'm happy to okay is there other board comments or questions yeah thank you chair quickly on the weight times some past experience with work at the VA there is no perfect measure and so it's a good idea to think about having an assessment of weight times from multiple perspectives in the in the presentation seen earlier this year they use the secret shop or patient surveys claims data so in addition to what we want hospitals to report to us I think we ought to consider additional measures from additional perspectives that may include patient surveys may include patient claims data but we won't we won't find one history has shown we won't find a measure that is suitable for everybody they all have weaknesses that's all thank you thanks for all the work in this to Patrick and team other board comments or questions I know I just want to back up a few points that were made by some of my colleagues especially on the weight times I think that we have to be very specific on what we're asking for and a lot was learned during the work that was done jointly with AHS and DFR and I think that Board Member Holmes has the right metrics for what we need to measure and of course if so much is going to be driven as far as increases based on workforce cost I think that those are entirely appropriate questions we're going to need those answers no matter what so just want to back those up and again like the rest of my colleagues I'd like to thank the team although I do disagree with the team's recommendation about setting a rate on the NPR I just feel that these have been so uncertain times and the impacts of the pandemic have affected each hospital so differently that having one number in my mind I just think it's a mistake and I think that we need to listen very carefully to each hospital and the story that they tell about what they're seeing what they've experienced and what they hope to achieve in the next year rather than trying to use any type of cookie cutter approach so those are my thoughts anything else from Board Members comments or questions if not I'll open it up to public comment does any member of the public wish to comment on today's discussion and I see Eric Schulteis Eric are you there Eric well I see a hand up Eric but I'm not hearing you so well maybe Eric while you're trying to figure out why we can't hear you I'll turn to Walter Carpenter thanks Kevin thanks to Jess for bringing up the wait times and her delineation of the wait times as a patient I've experienced them I wonder if another thing to look at is not just the wait times but why there are so many wait times and when the hospitals come up to the board later on wanting big fee increases which they probably will to pay for the traveling nurses because the other ones have left for whatever reasons we've got to look at really the bottom why that's happening and remember that all those costs are paid for by us the wait times are systematic they're embedded in the system I don't think it's you know whether it's referrals or not it's all part of the problems of the system itself thank you Walter Eric have you had a chance to figure out the technical issues or are you with us Eric Shultais from the health care advocate okay we'll keep moving on and Eric just raise your hand again if you actually do wish to speak or if anybody else from the health care advocate might be able to figure out what's going on there so next I'm going to turn to Mike Del Treco from the Vermont hospital association Mike good afternoon chair mullen and board members and Patrick and your team thanks for a thorough presentation I tried to write as fast as I could the notes from Robin and Jessica but you guys talk way faster than I can write so I think there's a lot here I did spend some time with Patrick reviewing the documents I was not going to comment but I didn't want anybody to think my lack of commenting was a vote of approval so what I'm saying here is I'll review these things I know Patrick is meeting with hospital CFOs on March 22nd I think we'll have a better handle on providing some more constructive feedback at that point as well so thanks chair and I appreciate your help and Patrick thank you for all the time you've provided in the past thank you Mike and I see that there are a number of hospital CFOs on this call and any feedback that you can get the sooner that Patrick gets it the better off we all are sure one other comment on the S285 is it right I think there's a lot of uncertainty of what's going to happen how things are going to roll out and I know that we're looking for specificity on how we participate I know the chief medical officers group that we have has been talking about moving forward in the next steps and certainly as this evolves they'll be plugging into this dialogue what that looks like I wish I could tell you but that's what I would offer in that space we truly appreciate that Mike as you know we're all going to be at the table for that discussion thank you is there other public comment is there other public comment I do feel bad that Eric had his hand raised and we didn't get to hear from him so if anybody's listening from the healthcare advocate if you could just let Eric know that we're really looking forward to hearing what he had to say and perhaps he could send any comments and writing and we'll post that to the website thank you so much just working on some tech issues but yeah let Eric know thanks a lot appreciate that Sam one last call for public comment is there any other public comment if not keep in mind that the board does have an open public comment period through at least Monday the 21st and likely longer but the quicker that the team gets the comments the much more time that they have for carefully digesting them and trying to factor them into recommendations for guidance that will be discussed at next week's board meeting and I plead with everyone to get comments back as quickly as possible Mike did your hand go back up again or is that still from earlier it did and I was just looking at my notes and I wanted to comment on one of the questions that Robin had around specifically the cost center piece there was some a fair amount of dialogue around that and it was it started from the point of view of how our revenues sort of allocated to value based performance and we had a conversation that said you know it's sort of like when you get paid you deposit your check in your savings account and then you spend things on your expenses so that's where it sort of moved to a cost center look if there is something that you're looking to be more holistically yeah that might not do it but that's why that word cost center came in because it's if your IE care coordination department grew if you are and how did it grow and what are the things that happen in there it's more identifiable from from that point perspective then from a revenue perspective so just some feedback on your comments thanks Mike no that makes sense I was just wondering if it would then miss things like the hospital had in kind staffing for the community health team and you know it may not be dollars that you can necessarily carve out like a department but it's efforts that they're making that supports you know healthcare reform so it works for you guys that's fine I just wanted to kind of express that so we weren't discussing information yeah I think it could I think I would have to look at the language specifically but I think it's general enough and if it's not general enough to catch it maybe there's something that beyond you know your normal expenses what else have you done like something like that but that's how it that's how it got moved to expense or cost anyway thank you thank you is there other public comment hearing none it's been a great discussion today I look forward to did I see a hand go up well it has disappeared again so again it's been a great discussion today I look forward to further discussion next Wednesday and hopefully we can start working through all the different issues that are going to have to be discussed and so thank you Patrick and team and Eric I see that you are alive did you want to jump in today I'm sorry I did I'm sorry for the delay I I apparently have made it all through the pandemic not having teams issues except for right now so apologies I guess I aside from so we will provide comments on the budget guidance you know we received it yesterday at 311 so it's not that it's missing it was just asked for I think that mode of interaction was from from the pandemic times I don't know if it's appropriate as we come out of the pandemic and I don't think it's something we've agreed to so that's what's a integral part in my understanding of developing this guidance so I think that's something we have to revisit we do have good examples of interaction with other staff teams so for instance the ACO team and my hope would be that we could have that level of meaningful engagement in the hospital budget process for the guidance development I have some concerns that haven't necessarily been expressed so they have in part about the use of inflation to come up with the staff recommendation for the MPR growth and not to beat a dead horse but I think there are some issues that I'd like to see around sensitivity time frame selected so there are seven pre-COVID time frames and six COVID time frames the earliest year has the lowest or second third lowest rate of growth so that's going to pull down the average or the calculation and make the difference look larger I would be interested in seeing some sensitivity analysis around the time frame and how that might change the recommendation I also want to point out that it may be the best we have but the CPI for medical services is a national number there may not be Vermont specific numbers for some of those numbers there might be regional numbers of course Boston has an outsize influence on that I think it might behoove the hospital budget team to communicate with the statisticians at the Vermont Bureau of Labor Statistics in the past I found them exceedingly helpful and they're also trained specifically in looking at wage, data inflation data they are contracted with the Federal Bureau of Labor Statistics so I just want to point out there are various reasons that can be moved in a certain way that methodology to produce exceedingly high numbers and unfortunately I didn't see the sensitivity around how they came at that I think also they you know the prediction that inflation last six months will just continue in the future to me that reads as a naive prediction 2% is an exceedingly high especially for what is it PPI historically that would be amongst the highest rate of growth so I have some skepticism about the prediction of course we can't predict things perfectly but to me it doesn't even read as reasonably the best we can do thank you thank you Eric and I want to apologize up front I'm saddened to hear that you weren't part of the discussion to me if the regulated entity is at the table so should and so we'll have those internal discussions here at the board but I want to apologize to you thank you may I speak on that please certainly we did reach out several weeks back to inform them that this process had been started so the opportunity was there for engagement all along however as we're bringing on a couple of new staff members we had to focus our attention in other places and so I think Mike Delta can also speak to that his involvement was not as in depth this year as it has been either so the opportunity was there it wasn't a closed door whatsoever and I was not implying that they did not meet any time frame of ours because it was missing they did receive the guidance yesterday afternoon that is true but in no way was I making a statement that the HCA did not deliver on expectations so I just want to clarify that up front and also I've been communicating with Mr. Peisch Eric's involvement is something new to me on this level I did not know that he was going to be our point person for that so I think we have a communication issue here that we've got to work on board chair just really quickly so at Patrick it's a exceedingly small office there are three of us working on this stuff effectively so you know someone is lead but obviously we're all aware and Sam is relatively new I will say I think there are communication issues to work out I took the email and the rest of the team I think did too from several weeks ago is this is how it was going to happen not an invitation for engagement that's good to know or that those are actually invitations for engagement but that was not at all clear to us I suggest Eric that perhaps you and I and Patrick sit down and have a conversation that would be wonderful because I think that we're all hoping for the same thing but I think right now we may be talking past each other so let's we hear you and again I apologize no but that I want to thank everyone for the hard work and effort that went into the presentation today again next Wednesday we'll come back to this so at this point in time 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 by member Holmson amended by member launch to all those in favor of the motion please signify by saying aye aye any opposed please signify by saying nay thank you everyone and have a great rest of the day