Good afternoon everyone and welcome to the Green Mountain Care Board. My name is Kevin Mullen, Chair of the Board, and we're about to get started. The first item on the agenda is the Executive Director's Report, Susan Barrett. Great. Thank you, Mr. Chair. I have a few announcements. First, I wanted to let the public know that Board staff gave a presentation on the 2021 legislative session, both to our Primary Care Advisory Group and our General Advisory Group, and we focused on the items that were related to the Green Mountain Care Board's work. Those slides can be found under today's Board meeting agenda and materials, and they're also posted on the Primary Care Advisory Group and the General Advisory Committee sections of our website if folks are interested in looking at those. The second update and announcement is that tonight we'll be meeting with our Primary Care Advisory Group. They're going to be hearing from consultants from DEVA and the group is going to be asked to provide feedback on DEVA's HIT, HIE strategic plan. And then lastly, public comment, ongoing public comment sessions, sessions that are happening right now are one, the ACO budget guidance, which will be announced by our staff today. We'll start today and I'll let them give you the details on when that will end in enough time for obviously the Board to consider those comments. We also have our QHP rate filings that are open for public comment. And then last but not least, as I've mentioned in previous meetings, we have an ongoing public comment period on a potential next agreement with the federal government that those slides that were presented to our General Advisory can be accessed through our website. And any of the comments we received were sharing with the Director of Healthcare Reform at AHS and the Governor's Office as they are leading the way on the negotiations. And that is all I have to announce. Back to you, Mr. Chair. Thank you, Susan. The next item on the agenda are the minutes of Wednesday, June 2nd. Is there a motion? So moved. Second. It's been moved and seconded to approve the minutes of Wednesday, June 2nd without any additions, deletions, or corrections. Is there any discussion? Hearing none. All those in favor of the motion, signify by saying aye. Aye. Those opposed, signify by saying nay. Let the record show the minutes were approved unanimously. So next on the agenda, I'm going to turn it over to Sarah Kensler, who is going to tee up the vital quarterly budget presentation. Sarah. Sure. Thank you, Mr. Chair. This is Sarah Kensler, GMCB Director of Health Systems Policy, and I'm here to introduce the Vermont Information Technology Leaders, or vital quarterly update, as well as their annual budget presentation. The Board is required to annually review Vital's budget. Per the budget guidance we approved, or that the Board approved on April 14th, the Board's review is focused on the following criteria. First, transparency. Second, public and stakeholder input. Third, alignment with the goals of the HIE plan. And fourth, alignment with the process that Vital and Diva, or the Agency of Human Services, undergo when they're contacting. In terms of process, today we'll hear from Vital. Adding to the list that Susan mentioned earlier, there will be a public comment period open until June 18th on the GMCB website, and we'd welcome any comments on that. And then I will be back in front of the Board on June 23rd to present a staff recommendation with a potential vote also scheduled for that day. Are there any questions from the Board before I hand it over to Vital? There don't appear to be any, Sarah. All right. Welcome, Vital. Thank you. I am Beth Anderson. I'm the CEO at Vital, and I will get us kicked off. What I'll do is I'm going to tell you who from the team is on the call today to present, but then they will each introduce themselves as we get to their sections, just to avoid the awkward who goes next. So today we have, I think, in order of the way you will see them, Bob Turnow, our CFO. Then you will have Carolyn Stone, who is our Director of Operations, Lauren Gilbert, who's our Director of Client Engagement, Frank Harris, who is our Strategic Technology Advisor, and Joshua Cheney is also on with for assistance. So as Sarah presented, the primary focus of our presentation today is to go through our proposed FY22 budget with you, but we also want to give some updates on how the current year is going, some key initiatives, security across the VE HI, and then we'll present our quarterly data to you as well. So just to kick off, Joshua, if you would go two slides, please. Yeah, no more, thanks, perfect. What I want to do is start with the foundation of what FY21 has looked like and how we think we'll end the year in some of our key achievements. So some of the main things I will hit on some of the high points. You'll hear about some of these from the team as we go through the rest of the presentation. Some of the things we've accomplished this year were continuing our support for the Department of Health and their COVID response work. Carolyn, I'll give you some more detail about what that has looked like a little bit later. We continue our implementation of the MedicaSoft platform. Key deliverable was reached in April and that was the delivery of the first blueprint extract from the new platform, which was a great achievement for the team. Maureen will talk a little bit about and has led some planning for the collection and sharing of part two and sensitive data. We've worked to ensure our compliance with the new 21st Century Cures Act final rule on the interoperability requirements. And we've also worked with many of our providers and healthcare organizations to help them also be sure that they're in compliance with those new regulations and how they impact them. We assisted one of our key partners and some of their partners with data needs during a cyber attack. We've created plans, policies, and procedures to use the VHI during emergencies. We've continued ongoing efforts to maintain security and availability of the VHI. And we have initiated this strategic planning process, which we are doing to be aligned with the HIE plan. Look at vital goals and directions for the next three or five years with a goal of having that done in the coming months. And we can follow up with more information on that as that work is completed. So Joshua, next slide please. So before we get into what the next fiscal year or contract year will look like, I want to also talk about some changes we're making to the current year's contract in conversations with Diva. And really, these changes are driven by a couple of reasons that I'll go over. One being there's a renewed focus on getting claims into the VHI. A quick, maybe at a slightly accelerated pace from what we had originally anticipated with the contract. So we're going to expand the scope. Originally, it was just Medicaid claims. So we'll be taking, trying to work with some of the private payers to get claims in the VHI. So the goal is to prioritize that over some of the other work. We also, as you heard us say before, had some delays in the Medica South project, both due to our focus on the COVID needs for Department of Health and also just lessons that we've learned as we've worked with this new vendor for implementation of their platform and better ways to prioritize it and line up the work. So what we're doing is, as I said for 21, we're expanding the work that we'll do for claims and the linking the clinical and claims data together. And we're going to push off implementation of a few pieces of the platform until 2022. And the key things that will change are launch of the APIs, the patient facing access to their data for apps to get access to their data. So that doesn't mean we won't be giving patients their data as we've always done, what will be a new way for them to get their data, as well as the upgrade of the platform to the latest fire version. So with that brings us then to what we think our 22 contract will look like. And as you all know from going through this many times with us is at this point, this is an anticipated contract scope for 2022. Diva has to submit a request to CMS to get final approval for scope and the final negotiations will happen in the fall, potentially early winter. So this is kind of our best gas and what we're proposing to CMS to be the scope for next year. And so, as I mentioned, a few things kind of shifting from 21, the upgrade to fire for launching the patient APIs. We really want to focus on enhancing and expanding the reporting infrastructure that we will put in place to allow for more customized reporting and hopefully self-service reporting ultimately on the clinical and potentially claims data. We will be enhancing provider portal, which we will be piloting this year, which will really provide some great new functionality, we believe, to providers to make the data really more usable and actionable at the point of care. We're going to be looking to transition to a new results delivery platform or tool to get the results into the EHRs for providers. We are going to continue our work with by state, which was a new work for us this year to kind of take their model of improvement and find ways to expand the work that they do with the FQHCs to a broader audience of healthcare organizations across Vermont. And so we'll be looking to continue taking the planning that's happening this year and expand that out. We're going to do transition to some existing reports to the new platform. Not exciting. And we're going to do our proof of concept or continue our proof of concept to see if we can help achieve some HEDIS reporting from the VHI and maybe eliminate some of the burden on providers to do some of the data collection and submission. So this is a scope of what's been proposed or will be proposed to CMS. Two pieces were also in conversations about that, that are not included in this budget, but we're hoping we may be able to include, would be advancing some work on incorporating social determinants of health in the VHI, as well as continuing the work with sensitive data and putting that in the VHI. So Joshua, next slide, please. That then brings us to our FY22 budget. As you know, we budget on a fiscal year, which is a July 1 through June 30, but we do contracts with DEVA on a calendar year. So the FY22 budget is kind of a split of deliverables from the two contracts. So just to give you a sense of what, what serves as the foundation of the proposed budget that I will present in a few minutes are a few of these deliverables on here. So it's completing implementation of the MedicaSoft platform, the work towards the R4 and the API, work to expand the data type, the data types, it's the claims, social determinants of health, piloting and launching the enhanced provider portal. Some work, more internally focused work we have on implementing is a more sustainable business model. Continuing the program that we've started or the Marine has really started since she's joined the organization of doing more outreach and engagement of our clients and really getting them involved in helping design future programs and services. We will as always continue to focus on and enhance our security posture as the landscape changes to make sure that we have protected the data in the best ways possible. And we will continue working with the Department of Public Health to try to find opportunities to help inform and support their work. And we've learned conversations with them about some really exciting opportunities to continue that partnership beyond just their needs for the pandemic but to the greater scale of their work. Finally, and next slide please. Just looking at the FY22 budget, you know, we do face some challenges and Bob will talk through more than just the ones that all hit, but I wanted to hit some of the key ones that I think will drive not just the 20 or are impacting the 22 and potentially future year budgets. One is if the last year has taught us anything, it's that we need to be ready to be flexible right between the pandemic and a cyber attack lessons learned with a new vendor. We've we had to be flexible to shift our work and focus on what the right priorities were at the time even if it isn't what we thought the prior spring that the priority would be. And we want to continue to be able to remain responsive to needs of public health and the healthcare community. A big change which I'm sure you're all aware of is that on September 30th the high tech funding sunsets. And so that was a 10 year funding that was provided under the RF program 10 years ago to help encourage the use of technology and healthcare and in healthcare organizations. And so that with that sunset CMS is going to continue funding of HIE work, but we're expecting it to be at much lower allocation level. So the state match won't kind of be leveraged quite as far as it has been or is currently being leveraged. So while that you'll see there's not a big impact to that there is an impact to that with our 22 budget, but then really as you look at our CY 22 contract and future years we're expecting a larger impact there. The unfortunate part is at this point we don't know what the new allocation levels are. So you'll see this budget was developed or this 22 budget was developed with a perspective on what we think the kind of likely realistic likely case of funding could be. Diva is submitting a request that includes different scenarios where they think there's a strong justification for different allocation levels, but we've tried to be realistic with what we think is the most likely allocation rate that CMS will come up with. But we will keep you updated as we learn more from those conversations. But that then leads to kind of the additional challenge we have is with the funding from CMS changing to continue the work of the HIE to deliver value to providers and payers. And the ecosystem is we will likely be looking to or we're looking to develop a sustainability model that likely includes charging for some of our services in future years. So that does not play into the FY 22 budget at all, except we're doing some planning now for what that will look like in future. And we're working with some experts to do some work there really to understand best practices at other HIEs, understand what some of the kind of needs and goals and gaps are here within our community. And we're doing that in concert with some of our providers to get some of their feedback and really to lay out what we think is a kind of an achievable sustainable model for the ecosystem as a whole and not just vital. You know, we will again, this is something that we have underway, we'll be coming back to you to talk about that as we clarify some of what our opportunities are, as well as once we really understand where the funding is shifting and what that looks like and how it's going to impact us over the next couple of years. So with that, I'm happy to answer any questions or Bob dig into the budget numbers for you. Does anyone have any questions for Beth? I have a couple of questions. This is Robin. Thanks, Beth, for the more detail around the fees and the timing of when you're expecting it. Personally, that's an area that I'd be very interested in getting updates as you come back with quarterly information just so that we have an understanding of where you are in the process and how that will impact the entities in particular that we regulate as well as, of course, other types of providers. And then the other area that I'm very interested to hear more about in the future is the claims and clinical integration. If maybe you have this for later in the presentation, but can you give us an update on how that's going with Medicaid claims? And then I was curious to know you mentioned working with payers. How does V-Cures fit into that? That's a great question. So Carolyn will touch a little bit on claims later. So I'm not going to steal her thunder, but if you have additional questions then, great. When it comes to V-Cures, so some of this work is actually being driven, much of this work is being driven by the HIE Steering Committee or really a subcommittee on claims. So you know that Sarah Lemberg does sit on. So she is part of these conversations. So we don't want anything to be a surprise for anyone. I think at this point it's really looking more to meet some more needs with Medicaid and some of the reporting that they want to be able to do and see like a proof of concept. Can we get the data in? Can we get from the payers in a usable format? And can we do the linkage of the claims and clinical? As far as where we go toward the future, you know, with Sarah, we started actually today, but looking to set up some conversations with some HIEs that do provide both APCDM, the traditional HIE services, so to speak, to see what those models look like and if there's opportunities for us in the future. But right now it's just kind of learning and exploring. Okay, great. Thank you. Did that answer? Okay, thanks. Yep. Any other board members have questions for Beth? Yeah, I have a couple of quick ones. I'm just wondering for fiscal years or calendar years 2020 and 2021, there clearly was a lot of fast moving decisions that had to be made and you've done a great job. It's, you know, to go on the website at the Department of Health and be able to kind of track your schedule and stuff relative to vaccinations and stuff. It was really, really done from my perspective seamlessly. But I'm wondering if the contracts that supported all that unexpected COVID work have all been amended and adjusted so that 2020 and 2021 are in a firm position to proceed with your 2022 contract? Yes, so we are still, we've, the 2020 contract, we were able to work through all of the changes and I do want to give credit like Diva and the Department of Health, AHS as a whole, they have been very supportive of our, they've made it, they've, you know, we kind of undertook the work with them with hopes that we would work it all out and they've been great partners and making that all work. And so I do want to acknowledge that they've been great partners to us. We were able to work through it with the 20, the calendar year 20 contract and funding and they were actually able to use some of the CRF funding that, I'm sorry, the really funding that was received by the state to help fund some of the work, which preserved some of the HIT fund monies. We are, we have agreed in the concept to the changes to the CY21 contract, but we still have to actually formalize those changes. I don't anticipate we'll have any issues, it's more just the documentation piece of it. And I think we're in good shape for 22. You know, I think we've tried to leave some, I'll call it wiggle room in the contracts to be able to be responsive where new needs might come up. But if we find ourselves in a place where we were, I mean, hopefully we don't, but if we find ourselves in a place where it's a much bigger ask more like we were at last March or April, we may have to look at changing contracts again, because that will impact our ability to deliver on what's in the contracts if we have to refocus on that intensively. Another question is you referenced that my slides are like out of sync now because of the addition of a new slide, but I think I can get my point across. You referenced on slide four, which I think is in the same place that originally was the cost of the cyber attack. And I'm just wondering, do you know what the cost of attending to the unexpected demands of the cyber attack were and whether or not any of that was reversible? We didn't do a formal accounting of that. It was a lot of overtime for staff, largely, what that what that turned into for us to be able to do the creation of the accounts and trainings all hours of the day to meet their shift. It's something that we did not because we were not ready to do that. That wasn't kind of a planned service that we had. We did not seek to ask for reimbursement for UVM. What we are looking to do though is kind of develop that more as a service with some more clear guidelines for what that could look like if we were to provide that service for other hospitals in the future and to give them a heads up that this would be the case and not just surprise them in the end. I mean, I don't mean to minimize it. It took work and responsiveness on our team side. We were happy to do it. I don't think the cost would be at all prohibitive for anyone. Like I said, it's really staff time that that results into on the overtime. Thank you. Other questions of Beth? Hearing none, why don't we go right to Bob in the finances? Thank you, Chairman Mullen. Good afternoon. I'm Bob Trinneau, CFO for Vital, and I will be presenting our FY22 budget request. While last year's budget submission focused on the uncertainty introduced into our planning due to the COVID pandemic, I'm heartened that while our plan changed during the course of the year, we were able to support the state of Vermont in its COVID response, and we appreciate, to Beth's point, we appreciate the state's flexibility in modifying our deliverables on our CY20 contract to enable us to do this. This year's budget was shaped through a collaborative effort with the Green Mountain Care Board staff to draft the budget guidance necessary to support the Green Mountain Care Board's deliberative process and discussions. The work scope and funding was worked out with our counterparts on the DIVA staff, and we believe this has led to a more focused budget process that is linked to the plans of the state and the HIE steering committee. So thank you to Sarah Kinsler of the Green Mountain Care Board for her help, and also to Emily Richards and Bashir Ben Said from DIVA for their help as well.  As Beth mentioned, we projected shifting funds from within the CY21 contract to meet new requirements sought by the state. This is expected to reduce the overall revenue by for FY21 by $912,000. We have some interference coming through. Maybe people that aren't speaking could mute their line. Thank you, Chairman. In addition, we reviewed expenses and have reduced them by $833,000 as work shifts into FY22. Lastly, we expect that we will be in a surplus position at the end of the year with $339,000 and sufficient cash on hand of $4.5 million for 195 days. Next slide, please. Our budget for FY22 is based on the following assumptions. While we have developed our estimates on significant discussions with our DIVA partners, as Beth mentioned, there could always be an unforeseen change to the CY22 contract given that these are estimates prepared prior to the approval of the state's funding request by the federal government and our final agreement on work scope and funds, which is projected to occur later on this year. Next slide, please. This chart is intended to show the magnitude of our contracts, including those that are yet to be settled. FY21 is shown as an estimate because there's still administrative work to finalize the work scope and a contract amendment with DIVA. We don't anticipate this is much of a rigorous effort, but it still is an item that needs to be completed. CY22 is estimated as it is in process. We expect that it will be finalized in the early part of the fourth quarter of 2021. And as you can see, since CY20, the DIVA contracts have been significantly larger than prior years, showing the investment the state is putting into the VHI. I will point out that the estimate for CY22 reflects a shift in work scope from development to operations as well. Josh, next slide, please. Moving on to revenue, as Beth mentioned in her overview, the FY22 budget has been shaped by the changes to the CY21 contract, where funds have been real allocated to expand the claims work scope and to perform preparatory work and planning for some CY22 deliverables, primarily the transition to R4 with the database and also the launch of the patient APIs. CY22 includes a larger amount for M&O, as I just mentioned. We feel that it more accurately reflects the cost of maintaining and securing the VHI, including the additional services implemented as a result of the collaborative services projects and the addition of claims. And just as a note, the all other that is included in this table includes fees for services such as Vital Direct, Patient Paying, the ADT feed, and the new route notification fees that we envision happening. Next slide, please. This chart shows the magnitude of contracts that make up Vital's FY22 revenue estimate. On the right hand side, I'm trying to show here whether the contract is settled or contracted or whether it is estimated to project the degree of risk of our financial projections. With a contract that has been awarded, the risk in realizing revenue is centered on the execution. Whereas with an item that we have estimated, there is also the added risk of the level of funding that will be available to us at the time we actually execute the contract. We've also included similar to last year a revenue contingency, although this year that value is less than 2%. Next slide, Josh. Moving on to expenses. This slide shows three years of expenses for Vital and includes the FY20 audited results as well as the updated budget that we did in January and a forecast for year end with the FY22 budget request for comparison. Significant areas of expense for us is labor, which is 33% of the total spend in our budget. Now, this is down from the year end forecast where it was 39% and significantly down from FY20 where it was 46%. This is driven by the fact that while we have modestly increased our labor, the other costs such as software and consulting have grown significantly and I'll touch on those in a moment. Our labor staffing is again projected to grow modestly from a projected 26.4 FTEs at the end of this year to 28.5 at year end FY22 and this is consistent with the labor staffing that we have projected in our FY21 updated budget back in January. The legacy be high hosting cost is 10% of our total spend for FY22. It's essentially consistent with what we anticipate spending for FY21. Moving on to information technology cost, these are projected to be 27% of our spend. The primary drivers here are software licensing cost contained within this budget line item is almost a full year of subscription cost for our new data platform. In addition, there are increases to storage costs on additional reporting functionality that's going to be added along with additional enhanced security capabilities in light of the continued cyber attacks on other healthcare organizations. Our consulting costs are a major driver, 22% of our total spend. We continue to use consultants or contract labor to ensure resource and subject matter expertise required to be delivered on our ongoing projects and new projects, including the aggregation of claims data and fire expertise. The bottom line for FY22 is essentially a break-even budget when CAPEX is included. Next slide, please. Another way to look at this is this pie chart, which gives you a view of the magnitude of the expenses and their proportion to our total cost. As you can see, the largest component of our total cost is labor along with information technology next, and the IT costs cover data security, network expenses, and software expenses. Again, the next largest category is consulting, and the spend here has increased to support the increased workload that we envisioned for FY22, including such items as completing the Medica soft platform as well as the Fire R4 transition and the APIs that Beth had talked about. Also, we envisioned expanded data types such as claims and social determinants of health will also be some of the work that consultants will be doing along with the launch of an enhanced provider portal and our continued outreach and client engagement work that Maureen is doing with her team. And finally, the development of a sustainable business model are items that we see consulting will be supporting us with. Next slide, please. This work chart is our current work chart. There are two open positions, Director of Technology right now and Education Outreach Specialist. Both of these positions are being actively recruited for. Next slide, Josh, please. We have been focused on maintaining a stable headcount over the past several years and have only added positions to take on additional work scope that we see is long term. Therefore, we use consultants to fill the short term needs when appropriate. Vital is a lean organization focused on meeting our stakeholder requirements. However, in some areas we're one deep in our positions. The org chart that you saw for FY21 included two open positions. The FY22 budget adds two new full time equivalents, two operations analysts supporting the claims expansion and interfaces along with a half time financial support position. In addition, the FY22 budget includes temporary staffing that we had brought on as part of our FY21 budget update. Next slide, Josh, please. The FY22 budget assumes that the additional FDEs that we're bringing on will all start in July except for the claims analyst which will start as part of the CY22 contract in January. One note is that the temporary labor that is reflected in FY21 is just a partial year while FY22 is a more complete year. Moving on to our benefits, we don't see a significant change to our benefit plans. Our plans expire 1231, 2021, so they are calendar year basis. So the rates are essentially fixed for the first half of the year. Now we do realize that there is some risk potentially in terms of rates, but we believe that it is manageable. Next slide, Josh. Moving on to indirect rates, this bar chart shows vitals indirect rates over four years. The bars have four pieces. The top two reflect direct cost or those costs that can be assignable directly to supporting the program, whereas the bottom two represent indirect or general business or entity level costs. As you can see, the line has grown somewhat over the year, over the four-year period, but not at the same rate as our direct expenses. Vital has worked hard to keep indirect cost in check over the past three years. And you can see with the addition of the collaborative services and future data platform projects that we have added significant direct cost to vital, which in turn reduces the indirect rate. And finally, as such a small organization changes in, either the base, which is the direct cost or the expense, the indirect cost can have a large impact on the rate. Next chart, Josh. This chart just displays vital assets by category over the periods of FY20, FY21, both the updated budget from January and our latest look at year end and the FY22 budget request with the intention to show vital financial resources that are available to us during the projected FY22 budget period. The majority of our assets are quick assets such as cash on hand and accounts receivable that are highly liquid. Our current forecast for the year end for FY21 is $4.5 million of cash on hand or 195 days. This easily covers the projected liabilities of $1.6 million. The budget for FY22 projects cash at the end of the year to be $5.2 million or 172 days. This again easily covers the projected liabilities of $2.5 million. In conclusion, we believe that this budget positions vital to continue to execute on its contractual requirements and the mission of using health information technology to improve the quality of care to enhance patient safety and to reduce the cost to deliver care. And that concludes my presentation. Do you want to field questions, Bob, or do you want us to keep going? Sure. I will be glad to field questions. Okay. Board members, questions for Bob? Yeah, I have a couple. It's Maureen. I guess first, can you talk a little bit about what the CAPEX is for this year? I think you have like $430,000, and I know you are under, I'm sorry for $22,000, and I know you're underspent in $21,000. So is some of that just moving to the next year? That's correct. Essentially what that is, the bulk is the implementation costs on our MedicaSoft new data platform.  That's why I put it as an item for the Board's consideration on the statement of activities. Okay. And then as you mentioned, the consultant expenses continue to increase, and I think they're up almost $1 million from prior year. And I know I had asked this before, but are there any opportunities to bring people in on staff to do some of that, which might be less costly than consultants? And then you have that expertise on staff. I know it's hard to hire and everything, but since you keep continuing to increase that number, it seems like there may be some efficiency there somewhere. Do you want me to take that one? Yeah, Beth, please. It's a great question that we keep looking at. You can see some of the shift for 21 to 22. We are looking to hire some of the expertise that we know we need. So one of the positions we're looking to hire is a claims expert, right? Now that we're going to have claims in the database, we don't want to contract for something we know we're going to need long term. But a lot of the consulting, the consulting that we have in the budget largely is staff that we won't need long term. So it's really to help get the implementation done. So either where we needed expertise or we just need more hands doing some of the work during the implementation, which really involves documenting requirements, doing testing on the data that just doesn't continue for long term. And we don't want to set up a lot of hiring for long term hire. I will say there is kind of one group within consulting or one position within consulting that I think we are going to, we will be looking at this year to see if we have a long term need for kind of transitioning that into an actual FTE. But we have paid attention to that. I do understand and appreciate your point that we don't want to be paying extra money where we don't need to be paying extra money. We also don't want to be hiring people for one one and a half years and setting up expectations for recruiting and what that looks like. Okay, great. And I just want to compliment you on your slides. They're Bob and the financials, they're very clear. So that's great. Thanks. Thank you. Maureen, can I just follow up on that quickly for a second? Beth, you had mentioned short term and long term. Can you just describe to me what long term means to you and short term means to you in terms of the consulting? Are you checking the consulting component of the budget for 23 to go down or is it going to be 24 when it goes down? I would expect it to go down. So some of the some of the change you'll see is some of it is getting through this implementation and getting the work done. Some of it has been shifts in what our needs are too. So even though the number has been a little consistent, it's been shifts in what what some of the expertise we need within there is too. So I would say we would look at and we have a hard and fast rule. I'm not going to try to represent that we do, but I think we would try to look at if this is you know some that we know we're going to go live in February next year and we will not need that role. We wouldn't want to hire that person. If we're looking at look, we're going to be doing claims work for the next three or four years. That's where we would look differently to hire. And we do have some people that we have hired as we call temporary employees. So knowing it was more than a six month gig, but not a permanent position. So we do have some of that already in place and we look to do that also. Great, thank you. Okay, Tom, I think you were trying to say something. Yeah, quick, two quick questions. One is I, you know, I hear you have your kind of profile of assets and on your submission, you also had a profile of unrestricted net assets and I went back and got got the number from FY 19 just to kind of get a longer view. And so it is your unrestricting that assets in 19 to 20 went from 3.5 million to 4.2 million, 21 forecast over 20 from 4.2 to 4.6 million and 22 budget, 5 million over 4.6 million. And I'm just wondering in terms of your sustainability model, I mean, I'm never, you know, I'm never going to have a problem with someone scrolling away money, but I'm just trying in terms of your your sustainability modeling, how do these these numbers fit? I just note that your projected unrestricted net assets for 2022 is a 45.5% of your projected expenses. So I guess I have two questions is how does this fit into with your emerging concepts of a sustainability model? And since most of this money is coming from Diva, do they have any discussions with you about your unrestricted assets? Take that one too, both. Sure. Or do you mean if you want to answer them? Well, the the buildup of unrestricted net assets is is basically the culmination of the, you know, essentially net income each year. And, you know, yes, we have a projected surplus. But as Beth has mentioned, we anticipate that in future years that state funding is going to be less than than what it is today. And that unrestricted assets really represent, in some ways, one component of our sustainability for out years. You know, obviously the other part of that would be alternative revenue sources. But I foresee that at some point, you know, we will need those funds to be able to sustain us through a potential linear. Go ahead. And do you mind if I just add to that? I think that's right. I think to more specific to one of your more specific questions, this is definitely part of what we're looking at when we think about kind of a revenue model and what that looks like. I think we're trying to be really careful to be sure that where we develop kind of fees that we are being true to what things are really costing and charging for what they're really costing. You know, we're not looking to make a significant profit off of this. We are a nonprofit and others are intent. So we want to be careful around that. I also think we're going to look to potentially leverage some of these monies as Bob mentioned to kind of help us make that shift to the new model. And also, we're looked to see where we could potentially invest some of these monies in some tools that would be value added for our customers and help kind of support their needs and their work. So it's definitely, we're definitely looking at how we can use some of those funds to develop that model looking forward. So one quick follow up. So where does, I mean, if you go back to an earlier slide, you can really see that the growth in total state contracts, you know, quite an accelerated growth. And that and certainly there may be risk that Diva can't do going forward with it, been able to do in the review mirror. But so where does Diva get the money for your contracts? Is it global commitment money or general fund money? Do you have any insight into that? Yeah, so our understanding is traditionally it has been HIT funds monies that which then are used as the match for the CMS funds and the which have been very generous match rates traditionally for our monies. Looking into the next year, I think it's going to be a mix of different sources and Diva's still working out what some of those might look like. But there's a potential for it could be some of the 1115 global commitment monies for a small portion of our work. But that is still that is not as as nothing as for CY 22 that is not a final look. Thank you. Okay, other questions or comments from the board? I just had a follow up to that last discussion. And I know that under the high tech dollars, it's often a 90 10 match or you do you have a particular match rate that you're assuming in your budget build up or you're just kind of ballparking dollars? We working with our counterparts at Diva. I know that they have put forth a number of different alternative funding schema, if you will, with CMS. And each of those schemas really has a different funding rate for them. And what we assumed it was based on a Medicaid population based formula, which we believe kind of is the worst possible case because originally Beth, correct me if I'm wrong here, but originally that funding was based on more of a provider based value rather than a population based value. Yeah, there are two components that go into what the board already knows. There are two components that go into the calculation. One is that allocation, which Bob is correct with. Currently, until September, it is based on the percent of providers that are Medicaid providers. And what kind of we're assuming is worst case is it goes to the percent of the population that's Medicaid on Medicaid, right? So that goes from about a rounding, but about a 96 to about a 32%. Then CMS will still be offering a level of match, which will be the more traditional number used to the 2590, but it's based on that allocation. So that's really where things are significantly shifting is at 96 to what we're thinking is around 32, 33%. Got it. Thank you. Any other questions or comments from the board? If not, we'll proceed to the next section. Thank you, Bob. Thank you. Thank you. This is Carolyn Stone. I am the Director of Operations for Vital, and I'll give you a quick update on where we are with our COVID activities. Josh, if you can go. Thanks. So as you know, we've been working with VDH to support the state's response. One of the ways we were doing that was providing data access and reporting. We've been providing the provider portal to the epidemiology team for their case reporting. That's been ongoing. We've also had an ongoing automated data feed for the daily health and human services reporting that hospitals are required to do. And then a new thing that we've done since we last talked to you or presented to you would be, we've been, we supplied data to support VDH's high-risk immunization registration efforts and helping them identify who could be potentially on that list. The other area that we really ramped up with over the last few months has been the lab testing and immunization data interfaces. Since the beginning, we've onboarded 14 new labs and have, I want to say, over 20 more in flight right now. We're working with VDH to prioritize which ones are their top priorities and bring those on as quick as possible. We also onboarded over 108 new immunization sites. Those were primarily focused on the major pharmacy changes in Vermont so that they could get daily reporting going to VDH. And then the last area that we had been focused on is providing emergency services, medical services, the provider portal access so that they can look up patients who they'll be transporting to understand their healthcare needs better. And then, you know, we continue working with VDH to look and see how the HIE can support these public health activities going forward. We know that we'll probably be working with some additional immunization sites and the testing labs definitely keep coming. I think we've gotten most of the big ones but as that area seems to be evolving and new tests are coming out, we just keep adjusting with VDH and staying in sync with them as to who the priorities are there. Questions on the COVID support? Any questions from the board on the COVID support? All right, then I'll move into the collaborative services update. So we wanted to give you an update on where we are with our implementation. As Beth mentioned, we completed our first major deliverable in April and that was delivering the clinical data extract to the blueprint for health. That contained all of the data elements that were their priorities. We've also updated our project schedule to reflect, you know, the capabilities that we're seeing and the prioritization of claims, additional claims data and then where this next wave is scheduled to be completed by September 30th which aligns with the end of our DEVA contract. So we will be taking the full clinical database live and that just expanding on the data sets that we brought live for Blueprint. We're also going to be establishing that claims database with the first production data for the Medicaid data definitely and we're hoping to get some other payer data in there as well. And then the provider portal will be live and ready for the pilot to kick off at the end of September with the first few initial users so that we can get some engagement with the provider community on the pilot and their feedback. And then the future phases of the project will include one care Vermont reporting, claims reporting, platform expansion and those patient APIs that were talked about by Beth. So next steps, we're going to complete the remaining validation and data quality work on that full set of clinical concepts for the database and then we're going to finalize our claims requirements, create some submission guides for claims data ingestion and validate the first file ingestion which at this point will be the Medicaid claims. And then we're also finalizing our portal requirements. We just finished that in May and the data validation from the database to the application, the provider portal application is in flight and also the functionality that goes with that. So that's our report on the MedicaSoft Collaborative Services platform and I'm happy to answer any questions you have on this topic. Are there any questions on the MedicaSoft platform? I have a couple. I was curious about the blueprint clinical data extract and sort of what the bigger picture plan is there. Because certainly I know from the blueprint executive committee meetings that providers had gotten used to getting extracts of data related to their medical home practice originally monthly and I know that was put on hold to implement the new technology but what's kind of the long term plan here with the blueprint extracts? You know we're still discussing what 2022 looks like. My understanding was that blueprint had been getting these extracts and providing them to on point on an annual basis and what on point was doing from there on I can't really speak to. So we provided the 2020 data to them in April so that they have all the 2020 data to do their analytics. We provide it to on point and blueprint and then the schedule has us providing another extract in January on the 2021 data and then looking at does this become a quarterly or does this become a view that blueprint has access to the data themselves. You know that that work still needs to be defined on what would meet their needs. They're definitely changing the way they're thinking about working with practices and providing data as well. So still much to be determined there but we do plan to provide at a minimum annually just like they had been getting from the clinical registry when it was decommissioned. Great and then you had mentioned some of the future work was related to OneCare's reporting reporting to whom? So right now we provide OneCare with clinical data elements that they ingest into their health catalyst system and so it's to replace that work because that currently is coming out of Vital's data warehouse and as we replace that data warehouse with the MedicaSoft platform we need to replicate that work in the new platform. So they basically take that data into their system directly from ours and we're working through those requirements right now with them on what would that look like? Do they want the same thing? Do they want us to format it differently? You know what exactly are their requirements? We also do provide some data directly into their care quality care navigator tool. We provide some admission discharge and transfer data that comes out of our Rhapsody data engine and that won't change. So we plan to just continue supporting them in the ways we are supporting them now and you know eventually I would love to grow that support for them but right now it's just supporting them with data that they've requested. Thanks. Are there other questions for Carolyn? Yeah maybe just one. Thank you so much. I'm wondering if you could talk a little bit about the pilot for the provider portal and just what types of providers are included in that pilot? How are they selected? How are you going to be evaluating that pilot for expansion and implementation you know fuller implementation? Just a little bit of that about background around that. Yeah I mean I'll take a stab at it and Maureen can jump in. She's really leading that effort. We're going to be starting out with a lot of engagement to find out which types of providers would like to be engaged and have the time to you know help us evaluate the new product and provide feedback and doing some outreach with those groups. We'd like to see you know some variation in the types of people we select so that we can get a good cross-section of feedback and then you know clearly it'll be in it. The portal will be an iterative thing where we'll continue to keep working on it as we go. Carolyn's spot on. We have a number of folks I think of as super users who don't know that we call them that yet but we'll be doing some outreach to talk to them and there's folks in that group across quite a variety of different roles whether it's EMS or administrative and support professionals at a practice to clinicians. Really it's there's some diversity there and we hope to engage a range and we do think that the piloting is going to take a number of different stages so there might be some really early basic user acceptance testing followed by a little fuller sort of beta testing of the tool and we're going to be able to roll this out over the period of several months early in calendar year 2022. So lots of opportunities along the way for feedback. Is there will there be an opportunity to include sort of non-users or little users in the sense that maybe this would entice them to be super users at some point? We've been thinking about about how to get to those folks because we absolutely don't want to design a tool just for the people who use it today so I don't have an answer for you about that yet but it's absolutely something we're thinking about. Great thank you. Other questions from the board? If not let's proceed. Great. So I'm Maureen Gilbert I'm the Director of Client Engagement at Vital and I'm going to provide an update about our work on consent. So first I'm going to talk a little bit about our general consent policy and how we continue to support that. We have continued providing consent education to participating organizations and offering tools to healthcare organizations for their use with patients. Right now that includes the development of a new website and there's going to be an updated consent education toolkit there. Something really accessible so we can you know with one link point folks to all of the resources that they can use to educate their patients whether it's in person with a brochure and a conversation or a flyer posted in their portal social media posts that they could use in their broader outreach. We're also at this point continuing to hold on broad direct to the public education tactics while COVID response and vaccination promotion messages require full attention. This just hasn't felt like the time to be educating about the health information exchange when there is this urgent health care topic that requires Vermonters full attention. Next slide please Joshua. So sensitive data sharing consent and that project we're seeing a lot of changes in that project that we'd like to share with you at this point and this is really based on federal guidance. So we had anticipated federal guidance clarifying the CARES Act changes to the 42 CFR part two data sharing regulations by late March and we were exploring some options for how we might share data that had been covered by part two substance use disorder treatment data and then the mental health care data that often rides along with that. We've been exploring some options it was I think becoming quite clear that folks needed real choices to consider rather than theoretical choices to consider. So we were anxiously awaiting the federal guidance that would make it clear what we could do here what kind of data sharing would be possible in the future but on April 9th SAMHSA announced that it intended to publish those amendments later in 2021. I think nobody's expecting that to be soon later in 2021 could mean a lot of things but I don't think anybody's anticipating seeing that before the November-December period. So with that in mind we've chosen to wait for those amendments before further exploring options for the sensitive data sharing design and that's something that we're doing for the purposes of maximum clarity for patients, clinicians and other stakeholders and really to minimize the burden on participating organizations who have offered us some of their time already and engaging around this topic but we think we're going to be able to make the best use of their time when we we know the options that are truly in front of us. But one of the other things that I learned in this sort of early engagement period where we were doing engagement across a number of different types of organizations and different types of clinicians including general medical providers and also folks working in the designated agencies people providing mental health and substance use disorder treatment. One of the things that became clear was that it was going to be hard for folks to really meaningfully consider the options without a richer understanding of the Vermont Health Information Exchange and I think that was particularly true in the substance use disorder treatment and mental health treatment communities who have not been our core clients in the past and so what I see as an opportunity while we we wait for the federal guidance is to do more intensive education with those provider communities and really get them ready to understand the choices that they have regarding sensitive data sharing and really there's no reason they can't be using our tools right now. There certainly are some of providers in those communities who are using vital access for instance to get information about their patients and we think probably more engagement with that tool will be a good way to understand the Vermont Health Information Exchange and its possibilities better. So that's where we're looking to focus this project for the remainder of the calendar year and then we're really excited to hear what's coming next from the federal government and pick that back up. Any questions there? Questions for Maureen from the board? On consent? Yes I have one question. Go ahead Tom. So I'm just wondering how things have evolved in terms of the integration of consent with the potential of adding social social determinants of health to the information base because that was an aspirational idea a while back but it's probably becoming closer and closer to being operational and I'm just wondering what the current thinking is on integrating the access to those kinds of records with the consent policy. I think it's an interesting topic for us to be thinking about at the same time as the part two consent and I think I'm going to kick this one over to Beth. I think some of this has to do with the way that data is shared by our partners and the agreements that they make with their their clients or members around that data. Yeah I would agree with Maureen. I think this is something we have to spend a little more time on only because we're still defining what social determinants of health mean and what data items those are and at this point I don't think we can consistently say if it's social determinants of health that we collect from providers that are questions they ask the things your provider might ask you like do you smoke do you have how many drinks do you have during a week or if we're looking at actual data sets from different areas like if we were to talk to say corrections or economic services and I think until we have that scope figured out it's hard to answer what kind of the guidelines would be around sharing that data but absolutely a really important question that we will have to be asking and looking at as we think about incorporating the data. So I think I'd have to ask to commit to come with more information as we better understand what the goals and intense are. Thank you. Other questions from the board for Maureen? If not we'll proceed to the next section. Good afternoon everyone I'm Frank Harris I'm the strategic technology advisor for vital and with our director of technology currently under recruitment as Bob mentioned I'm going to be giving you the security update today and I know this is an area that's gotten a lot of focus recently with what we've all been seeing in the national news but I'll say that this is an area that we continuously have an intense focus on at vital and we're going to continue to do that. So if you could go to the next slide Joshua. So these are some of the things that we've been working on recently. The first is in the area of identifying and analyzing risk and I think as the board has heard in the past each year we have external healthcare security experts assess our entire security program from top to bottom and and recommend areas for improvement and we did that assessment in February and just last week through a detailed review with them of the results. They do a complete program assessment which includes procedures and policies compliance and technology details and we were very pleased with our results this year. What happens from there is each year we develop an action plan which we call a plan of action in milestones that is based on their assessment and we're creating that plan now we collaborate really closely with the agency of digital services on that plan they have a security specialist assigned to our program and who is excellent and we collaborate with her very closely. We meet with them each month to review our progress against our plans and priorities how we're prioritizing the initiatives that we're going to do and any significant decisions that need to be made about those things. So we're going to continue with that process. In the next area that we call protecting end points and end points is what we call PCs and servers. So basically anything that runs programs within our environment and we've been working on a couple of really significant technology initiatives in that area. The first one is application control and that's a technology that controls all of the programs that run in our environment. So it locks down the entire environment and allows only pre-approved programs to run in our environment on our servers or on our PCs and we've installed that software we're implementing it now as you might imagine it's a pretty challenging implementation because it involves identifying and categorizing every single piece of software that runs in the environment but that's progressing well. It's just going to be a very significant protection in the environment and when we get that completed. And then the next area is around next generation anti-malware or a lot of times people would call this antivirus and we have implemented that technology that's in place and what that refers to is the reason it's called next generation is because conventional malware for years and years has really been based on identification of known threats. So a piece of malware that is known to be out there in the world and it can recognize that and prevent that from running but given what's happening in the threat landscape it's really important to go beyond that now in what next generation anti-malware does is it will raise alerts not only based on known malware but also any unusual or suspicious activity that occurs in the environment because the trend that's out there now in terms of security threats is that hackers are leveraging legitimate tools to cause damage within the environment and so it's important to be able to recognize when there's abnormal activity happening and so we have that in place now and that's a really significant step forward. And then the third area is what we call ensuring resilience and what this refers to is that really what's happening given the threats that we're seeing in the activity that we're seeing out there in the world that the industry strategy now is to look beyond preventing intrusions and to really focus a lot on the what if an intrusion occurs, how you can react and mitigate and recover from an intrusion and one of the things there is that it's really emerging and becoming increasingly important is that speed is essential when an intrusion is detected it's essential that you react quickly to prevent damage and there's usually a small window of opportunity to once an intrusion is detected to prevent something bad from happening and as we've mentioned to you before we previously had implemented what's called a security information and event management system that collects data from throughout our environment about what's happening and we have a security operations center partner that monitors that system for us 24-7. Well what we've added to that is with the next generation anti-malware that we implemented we have a specialist partner that looks at the suspicious activity that might be identified by the anti-malware and they are an expert security resource that monitors that 24-7 and they are empowered to intervene into our environment to stop an intrusion if that occurs. The software itself is intelligent and will prevent a lot of intrusions but it's immediately investigated by an expert 24-7 if there's any suspicious activity and we're reviewing other opportunities for future enhancements in this area focused on the things that I mentioned about how we can react or mitigate or recover if an intrusion should occur. So that's my update for you today. I'm glad to take any questions. Questions for Franco? Any board questions on the security enhancements? Hearing none we'll proceed to the next section. So we we know we're over time here and we have eight slides left where we can provide a little bit and more information about our quarterly report. I just want to check whether you would prefer that we try to run through this efficiently just skip it and just take questions we're happy to handle this in whatever way the board prefers. I think you run through them efficiently and then we'll go to two questions. All right, we will end for efficiency. Next slide please, Joshua. So this is the percent of Vermont patients who have opted out of the Vermont health information exchange. Currently at 1.4% a slow slight decline over time here to be expected as we are every month adding quite a number of new users to the health information exchange. I believe it's 10 to 15,000 new users a month or I should say individual records a month. Next slide please. So this is the queries by organization type and you can see the distribution here of who's using the tool the most. Certainly hospitals are our biggest users and this does include queries during the cyber attack and we see a great amount of use here as well from federal and state agencies and this includes the VA and DOD as well as our own more local users. Next slide please. This is the number of queries a month in vital access. You can see of course that very dramatic spike during the cyber attack but I think you can also see here an interesting increase over time to about 20,000 little over 20,000 queries a month now which more than double sort of the rate about this time well much more than double the rate this time last year but where we were at sort of on average last year. Next slide please. And this is queries of the Vermont health information exchange via eHealth exchange. Most of these queries coming from the VA and DOD we did understand that they were using this this daily in their workflows and that there have been some changes in their workflows recently so we're asking some questions about that and we'll be tracking this over time. Next slide please. Results delivery by results type so this is the delivery of laboratory results radiology reports and transcribed reports directly into the electronic health records of the ordering clinicians and you'll see some really some steadiness here I think is the story. This is results delivery by organization type so who is who is receiving these results on this slide and you'll see quite a lot of use here by federally qualified health centers receiving the results from the hospitals and labs in the state as well as independent practices being big consumers of this data. Next slide please and I will give this one to Carolyn. Hello and you know so Vital had a contract target of 30 interfaces and 25 public health interfaces in 2021 and thanks to all of the COVID work we've done we've met both targets for this work. We're continuing to work with DEVA, agency digital services, Department of Health and other agencies to support data needs in responding to COVID during the second half and the other item that we'll also be working on is with the steering committee Asia E steering committee on creating the claims data connectivity criteria in conjunction with our implementation guide and reviewing the existing criteria to include in the HIE plan this fall. Next slide. And the last area where we are reporting on to you this quarter is on meaningful use and security risk assessment consultation and we continue to provide that service this year. We are contracted for a lower amount of hours this year in our contract which is why you'll see the hours are a little bit lower but we're still able to respond to those who would like these services and that concludes our report. So at this point board if you have any questions about any of the 40 slides go ahead and after that we'll move to public comment. So any board members? I just had one quick question on the pie charts in the last segment and I'm just wondering from you folks in the field whether or not the queries by organization and the results delivered by organization type does that reflect what you'd expect or are there areas there that where you think there might be potential for growth? You're going to speak to that? I think that there's always potential for growth in results delivery area and in the queries area. I think there's still as part of our education and outreach campaigns we're still discovering people who don't know who the VI is and what we can provide. So I think that there is growth in those areas that can still happen. I think the new platforms will probably be able to accelerate that in the future. Thank you. Any other questions or comments from the board? If not I'm going to open it up to the public for public comments. Does any member of the public wish to comment on the vital budget? And I see that Ham Davis has his hand up. Ham? Thanks Kevin.  But I'm curious. I'm curious that in talking to people about the overall issue of health care reform, the whole issue of changing reimbursement from future service to capitation, what are the most persistent questions? I'm not talking about health care experts. I'm talking about ordinary people who are smart, but who don't really know anything about this. One of the most persistent questions is if you shift from future service to capitation, are you building in a huge incentive for underuse? Myself, I've never really seen any underuse and I don't so. But at the same time, when people ask me that, they ask me if I really know, if I'm sure of that, how do I know? And I realize that the question is I really don't know. And so I'm very curious about the extent to which this extremely assertive stuff, whether we're going to be able to see something about health care quality that is going to be accessible to the public. So you have the underuse question for people who just don't understand it very much at all. You're already on track to look at potential overuse in your sustainability stuff. I just don't see how the public engages with this. I can just guarantee you that no member of the public has grabbed the faintest idea of what this single thing has been talked about for the last hour. Nobody's going to know anything. And so I just think that so later we're going to have to do something here. For instance, the most basic thing is that for many years, and still I believe, Medicare puts out two hospitals, results about Medicare quality, and it compares quality and cost across the whole system. And it puts out these little diagrams that have circles and colors and it can be in four different quadrants and so forth to get a sense of that. I just think that what I'm just curious about is the board happy with this? Do any of you get asked questions like this? What is the actual, what is the public, how does the public actually know anything about the actual productive results of the health care system in the month? I think you're really directing the question to us and not to Vital, aren't you, Ham? Sure. I mean, well, yes, I mean, because I have no idea what I know. I have no idea what they're talking about. When you're talking, Kevin, I get it exactly. So yes. You might be in a club of one, Ham. Well, you know, well, anyway, that's my question. I think it's something the board needs to consider because whatever the performance of the board is, the reality is that the legislature, and not just the legislature, anybody who thinks, I think you heard this from Mike Fisher, anybody who starts thinking about this and starts saying that we really need to figure out something else, that we really need to get a better look at this.  That's it. There is no place there. And I would say at the Green Mountain Care Board, Ham, there are several really measurements. If you take a look at, for example, the work that Michelle degree does for the board on the quality measurements, I think that's really important information. I think work being done for us now by two subcontractors is going to be very, very helpful information, not only to the public, but to the providers as well, as far as utilization.  And I do think that we have the tools to make sure that we can get the porridge just right. Well, I appreciate that, Kevin. And can I just just get some technical because it's just hard to do, but can you just quickly name the two consultants? I've been calling them. I've known about them just either last year. I just call them Joe and Schmo. Can you just tell me who they are quickly? Or should I get it? It's Berkeley Research Group and Burns. Okay. Thanks, Kevin. I appreciate it. Okay. More. Hi. One question, one comment. The question is for, I believe for Carolyn Stone, has to do with the Medicaid claims. I'm curious about the age of the claims that are being used in this pilot. One of the supposed disadvantages of the claims is they take a year to go from raw to seasoned to mature claims that are actually paid for. But in many cases, it's what was billed for that actually happened, whether or not it ever got paid for. So I wondered what you're using in your pilot. Right now, we're discussing with Medicaid that we will use their post adjudicated. So however long it takes them to say we've settled this, it will be. That doesn't mean that we won't be able to take earlier claims in the future. It just means that that's where we're starting right off the bat. Okay. Thank you. It's not much of an advantage over vCures if you're waiting until these are actually adjudicated. I don't believe although others know this better. But let me just switch to the philosophical question, which is for Beth. So the HIE is a public good. There's no way around it. There's a tension here. So how do you balance the tension between what's largely a public good and the need for a business model? Who's going to pay? How are you going to determine the charges? That's a great question. And that's some of what we're working through now. I think you're right at its core. We look at the data as a public good. But as the funding shifts, we want to be able to maintain the functionality. So what we're really looking at is some of the services we offer now are really services that we're looking to provide in the future, being more value add, saving work, being operational efficiencies areas where we can really add value to the organizations that use and whether it's existing providers that we work with or potentially new partners that we have where we can add additional value to their work and generate revenues in that way. And with the hope that it's not for kind of those, as you mentioned, like the more utility foundational services. What if a pharmaceutical company came to you? They'd be very interested in this data. That is not the direction that we're looking at going, right? We are guided by consent policy. We are guided by the the use policy that's included in the HIE plan and our service agreements that we have in place with the partners that provide the data or submit the data to the VHI. And we will kind of remain true to what those look like. And kind of commercial purposes is not and included in those purposes and in those agreements. Thanks. Thanks. Thank you, Mark. Great questions. Other members of the public, any comment on the vital budget? If not, Beth and team, great presentation. We learned a lot today. As you heard from Sarah at the beginning, she'll be coming back with staff recommendations. Sarah, did you want to say anything at this point in time? No, just to thank Vital for coming in and for a comprehensive presentation. Thank you. Thank you for having us and for your help, Sarah. Thank you. So now we're going to pivot and transition to a discussion of the fiscal year 22 accountable care organization budget guidance. And I'm going to turn it over to Marissa Melamed and Sarah Tuxbury. Marissa, Sarah, whenever you're ready. Hi. Good afternoon, Mr. Chair and board members. Can you see and hear me okay? We can hear you fine. And now I see you as well. Yes. Great. So my name is Marissa Melamed. I'm the Healthcare Policy Associate Director at the Green Mountain Care Board and the Administrator of the ACO Oversight Program. I'm joined in my remarks by Sarah Tuxbury, Health Policy Analyst. I'm going to walk you through the guidance today and Sarah is going to review the certification slides. We also have the rest of the ACO oversight team on the line in case they can help answer questions or provide any additional detail on areas they worked with. This is definitely a team effort across Green Mountain Care Board teams, including health systems finance, policy, data and analytics. And my job is to bring it all together for you. So I'm going to go ahead and share the slides. We know that you can see it. Sometimes there's a little bit of a delay. Yeah, we can see it now, Marissa. Great. So here's the agenda for you today. Pretty standard background. Our authority will go through the 2022 certification eligibility form and the 2022 budget guidance next steps and have an opportunity for board comments and public comments. So the ACO team last spoke with you on May 12th to debrief the FY21 ACO process and to set priorities for 2022. You discussed at that time with our consultant Michael Baylett on core competencies of high performing ACOs so that we could consider how his national research and recommendations might inform our process. Since I last spoke with you then, we have reviewed the draft guidance with the Office of the Healthcare Advocates and One Care Vermont and incorporated feedback in some areas which I will note for you. From this work, the year's guidance is framed with the priorities, goals and considerations that you see on this slide. And that is overall to collect information on ACO financial and quality performance, have our analysis and decisions be data driven, improve our regulatory alignment across screen mount care board processes and move towards standard reporting and templates with metrics and definitions as much as possible. There are also the continued goals and considerations that we've been working with since last year that you see below. The one that I want to just sort of call out for you is number four timing of information request. So the guidance that we're reviewing today is the budget guidance and we're trying to make it focused on the building blocks of the FY22 budget. We have been working on an ongoing monitoring plan and reporting manual to collect information to help us monitor the performance against the budget. And that's some things have been pulled out and put into that manual. So I'm going to try to make that clear for you as well what goes where. Our statutory authority, you've seen this slide many times before. There are two processes outlined in 18VSA 9382. Certification is one time and then with ongoing eligibility that form has become fairly standardized over the past couple of years with necessary updates that we verify each year. The ACL budget is the annual review of the ACL's finances and programs and the standards and requirements by which we review the submission are in the statute and the rule and there are requirements in the all payer ACL model agreement. And the other thing I'll note is that the coming budget year is 22, which is the last year of the current agreement. And so we have sort of chunked things 2018 to 2022 where appropriate because we're now collecting information on full five years as it's available. And to orient you a little bit to the documents that are posted in the workbook, the draft materials that I'm reviewing today are posted on the Green Mountain Care Board website under today's meeting materials that includes the certification form, the budget guidance, the attachments, the appendix workbook, the ACL reporting manual that I'll mention is coming soon so that people can view that and see specifically what's in it. As well the slides that I'm going to go through substantive changes are highlighted, I'm sorry, are underlined so that you can see what's different from last year. We did build this guidance off of last year's template. And in the posted documents those substantive changes are tracked. I didn't track every little single change like dates, try to keep it as clean as possible so it should just highlight what the material changes are. All right now to get into it I'm going to turn it over to Sarah Tupesbury if she's ready to talk to you about the certification eligibility verification form for 22. Hi all this is Sarah Tupesbury for the record. I'm Sarah Tupesbury with the Green Mountain Care Board. Can you hear me all very well? Yeah okay just checking before I dive in. So this slide that we're looking at and for those of you on the phone we are looking at slide number six. This is a slide that the members of the Green Mountain Care Board and the staff have seen used quite a bit in the ACO oversight process. But it's just an orientation slide and a reminder for members of the public that we are not certifying One Care Vermont this year. They were certified several years ago and what we're doing with this certification eligibility verification form is just ensuring that they're continuing to meet the requirements set forth in rule 5.0 and the statute. So what you'll see there are those 10 bullets listed out. Those are the 10 sections in rule 5.0 that specifically address certification criteria and these are the 10 areas that we really look at in the certification eligibility verification form and that we ask specific questions of One Care Vermont so that we can ensure that they're meeting those requirements year after year. Marissa if you could go to the next slide please. Okay so then this slide is showing you and this is slide seven for those of you on the phone. This slide is showing you that for FY22 in the form there have been just a few material changes that we've made since last year and I do want to note that last year when we presented the FY21 budget guidance to you there were no material changes so these are some of the first changes in two cycles really of budget guidance and certification eligibility verification that we've really made. So for the FY22 form those changes include that we are asking a question about One Care's 501C3 status. We determined that this particular change from One Care for One Care becoming a non-profit falls under the certification requirements so we've asked a question about that. We've also included One Care's executive compensation information in the certification form this year and those of you who are you know come to the Green Mountain Care Board meetings often from members of the public will remember that our lawyer Rost McCracken did a presentation a few weeks ago about that and you can find some information on the board website about the executive compensation guidance as well. We added updated language on questions about mental health access, pay parity and addressing adverse childhood events. There's nothing incredibly substantive and like large material changes as it says it's updated language and that's really where we left it. Something that's an improvement in my mind and I found really helpful doing this exercise was that we also added citations at the end of every question in the eligibility verification form so that One Care, the Green Mountain Care Board anybody who's using and looking at the form can tie the specific question directly back to the section of rule 5.0 where that question and that requirement falls. So that will be really helpful in both review and I think for members of the board looking back if they're interested in seeing really why we're asking that question. A few administrative things. The form will be posted on the Green Mountain Care Board's website. When we issue the budget guidance on July 1st the form will be completed and submitted by One Care on or before September 1st of this year and that's really all that I have for certification. I'll hand it back to Marissa unless we plan to do questions on certification now or at the end. Is it going to hold questions till the end and then open it up? Great. I'll hand it back to Marissa. Thank you Sarah. Yeah that makes sense because there's some overlap between certification and budget so you can hear the whole package and then let us know questions you have. So to orient you this is the table of contents for the budget guidance. The parts and the sections are the same as they were last year. The timeline for the submission is that we issue the guidance both the form and the budget by July 1. The certification application information is due by September 1st so that we get a month jump on that. It also often provides some helpful background as we go into the budget review. The budget submission is due October 1. The ACO budget hearing is scheduled for November 10th this year. It's a couple weeks later than it has been in the past to give us more time for review and analysis. Also in November we hear from the ACO and payers on their 2020 quality and financial performance and we present our analysis and recommendations on December 8th so that we can vote by the end of the year tentatively scheduled for December 22nd which is in line with previous years. We issue a budget order usually by the end of January or early February and then as you heard a couple weeks ago in the spring hopefully we can stick with that end of May timeline that we had this year. One care comes back with a revised budget which is a new standard process that we've implemented so that we can get updated numbers based on their final contracts and attribution because as we all know their budget is built on assumptions that they have at that time but their contracts are not tend to be finalized by the public payers or usually the end of the year and the commercial has been into the into the next year. All right so now to dive in section by section so the introduction summarizes the purpose of the document the statutory authority, verifications under oath, participation of the healthcare advocate and requirements for requesting confidentiality there are no changes to this introduction. We did update the language around COVID-19 which was of course a new addition last year and what I will draw your attention to here is that last year we waived certain questions that might not have been relevant under the circumstances or were maybe made to reduce burden but this year after discussion we have reviewed those questions incorporated the relevant questions we no longer saw a need to waive any questions and expected a year into the public health emergency that one care who does not provide direct services to patients has been able to update there or adjust their operations to the new normal and answer the full scope of questions that we have. So just to give you an example of questions in section eight we had some questions about the fall pair model goals that were waived last year we've re-incorporated those in sections four and seven we asked some HSA specific questions which we removed because they're no longer relevant based on their risk model which does not use HSA targets anymore so really we just removed questions that weren't relevant and kept anything that was. Section one on ACO information and background this is the executive summary for the budget narrative again we want the budget narrative to be focused on budget assumptions and limitations so we added some clarifying language to number five their key assumptions and limitations we added a question about lessons learned from the public health emergency one year in and then we added back in attachments A and B which were visuals that one cares provide to us in the past on the ACO network and ACO hospital participation grid that we waived last year just to you know use some of the reporting and we again we have broken out some reporting requirements into our reporting manual so you know in this section or anywhere in the budget one care can refer to those reporting requirements if they're relevant but you know not directly in the guidance here and we are also looking for one care to site the evidence base or data relied on where relevant section two is the provider network section there are three areas in this section the network development strategy network data that's collected and the provider contracts so what's new here is so one in reporting one care does submit their network development strategy for the coming year in the current year so they submitted their 2022 network development strategy just recently in May because they're working on that now to develop their network by expected September and October so I updated this language just a little bit to acknowledge that and have them sort of give us an update to what they said in May and now where are they in that network development strategy when it comes time for the budget submission and this should include anticipated changes to the provider network areas and growth into client and we ask them to quantify that general observations of drivers leading to participation decisions and challenges and opportunities with their network recruitment the network data collection is an area where we had some good collaboration with one care and made some helpful updates to the templates so there are two templates in this section they are 2.1 the organization list and then the provider list the green mountain care board and one care collaborated on a data dictionary to better describe the variables and the contents of information in both the contracted entity network and the individual provider list one care updated the payment type fields to represent the method of payment for the contracts and clarify those so these are now standardized to include fee for service fee for service reconciled fixed perspective payments unreconciled AI which is Medicare only all inclusive population based payment this also has that an indicator for participation in the comprehensive payment reform program and then an NA to represent if an entity is not participating with the payer and there's more work to be done this is the collaboration between our analytics team and our ACO team and one care to improve this provider network data collection and so we think this represents an improvement to help make this data more usable and the GMCB analytics team is continuing to work on on developing this list next up is section 3 the payer program section again this pretty standard not huge changes here we collect the scale target initiatives and program alignment form so that we can provide analysis with the contract against the requirements for qualifying for qualifying for scale and alignment of quality measures we asked them to explain changes across their portfolio payer programs new or terminating programs changes to existing programs and explain if they're not scale target qualifying we also have questions specifically about expansion of fixed perspective payments true capitation or otherwise and how those fixed perspective payments are calculated for each program something that we updated here is the next underlying bullet points which is just we've always sort of written this with an assumption that maybe the contracts will be finalized but we know that that doesn't work with the timing of their business processes so we've updated this language just to recognize that the payer contracts are likely not finalized by the budget submission so that the the narrative and the data should be as complete as possible given the information that they have and that contracts must be submitted within 10 days of execution and that the Green Mount Care Board may request an update on the status of contract negotiation at any time often or this is confidential so it's done as as needed but it is a way that the board can request more information on those contracts if needed through executive session and then there is a there's a question that's been in here for the past couple years about the expanded Medicaid population which may be more appropriate to move to reporting it's still in here because we wanted to include this question from the HCA which is what are the lessons learned from the expanded Medicaid population that could be applied to the commercial payer programs all right section four we did a lot of work on this section in collaboration with OneCare and to more accurately collect data from them in alignment with their risk model we were able to update templates 4.1 and 4.2 and eliminate templates 4.4 and 4.5 because the data was either incorporated into the revised templates or is no longer relevant to the risk model so I'm going to talk you through those changes as clearly as as I can so the new template 4.1 is total cost of care performance by payer total ACO wide and we do have 2018 to 2022 that we recognize that data will not be available for all of those years this template represents OneCare's arrangements with payers total cost of care targets are set by payer program and then settled at the close of the year and as you know there's a lag in settlement about close to a year the financial results from the prior year presented in November as I showed you on the timeline the updated template number two 4.2 is settlement by payer by HSA so this then takes the total settlement by payer and shows you according to the risk model how it is distributed by HSA so this represents OneCare's attribution and settlement by HSA or risk bearing entity 2018 to 2019 are based on HSA targets but then as we heard in 2020 and 2021 that model was changed to an ACOY targets which are then prorated by attribution so these new templates capture the data in this way and I think a good improvement here is that it shows as much data as we have year over year 18 to 22 so you can see it in one template as opposed to having to compare across templates the way it was set up before so the objectives here are to report total cost of care targets by settlement by payer in 4.1 and to report settlement by HSA in 4.2 and then what we are calling the HSA accountability strategy in the narrative which I'm going to show you in a minute with the question also to we want to provide actuals where available and projections if not so we asked OneCare to note that and expected total cost of care for the budget year and then we want them to discuss assumptions for projections and budget and adjustments for settlement and like I said we want to collect data as available 2018 through 2022 so just to go into the narrative so you see how we updated the question based on these new templates the 4.1 which is total cost of care performance by payer total ACOY we asked them to explain the drivers of expected versus actual total cost of care results by payer program to provide actuals for prior year if actuals are not available to provide projections and the timeline for when actuals will be available to provide projections for the current year and for the budget year to provide expected total cost of care what is expected that you're building your budget off of and to recognize any relevant assumptions for projections and budget figures for example based on historical seasonal spend plus a particular rate of growth etc and to describe any adjustment factors used for calculating the settlement result then on the second template which is settlement by payer by HSA we asked them to explain the methodology by which the ACO distributed funds by HSA including all adjustment factors used for calculating the settlement distribution for example risk mitigation market any market factor adjustments adjustments for local performance casement mix etc and to discuss the ACO's total cost of care accountability strategy at the HSA level so we break that out into three parts how is the ACO using total cost of care data at the local HSA level to identify high value and low value care how is the ACO helping hospitals and other community providers to reduce low value care and lower their total cost of care at the local HSA level and what evidence you have that the ACO local accountability strategy is working so this these updates are to help us recognize that one care has moved a risk model that shifts local accountability and if if the settlement is divided out proportional to attribution then how are they adjusting for performance by HSA we have discussed these templates with one care we understand that they're looking at measures for HSA account for accountability and so at this time we don't have a sort of data collection template here we put the question into a narrative and also I will note that some of these updates you know as much discussion during the Michael Baylor presentation around one of his points which was systematic evaluation of opportunities to reduce low value affordable and unsafe care to inform changes in care delivery and this is how we incorporated that topic into the guidance all right so then there's another template 4.3 which is projected and budgeted trend rates by payer program there's no change to this template the objective of this template is to discuss the underlying assumptions for the trend rates to discuss the budget growth rate versus the ACO growth rate over time excuse me to discuss the approach to calculating base experience and we also added in here it may be repetitive but again this note about you know in references to this template how the ACO's total cost of care accountability strategy allows providers to benefit from their ability to provide high value care and impact total cost of care growth just to make it clear this is an important question to us these are the two templates that we propose removing total cost of care budget year targets by payer by HSA the rationale for this one is that this one is that 4.4 was the budget year and all the years are now incorporated into 4.1 and 4.2 so it's no longer needed 4.5 is a template that reflects data collection on home hospital span versus spend at UVMMC or Dartmouth or other hospitals and was created for the outdated risk model where total cost of care targets were set by HSA I want to emphasize here that we're with removing these we're not trying to remove any reporting requirements we're trying to collect well not have things that are duplicative and make sure that the data we're collecting is relevant we may want to think about 4.5 and what the objectives were there to see if there is another way we can collect data around spending in and out of the home hospital given some of the information you've heard about patient migration and such but I I do not have a proposal for you on that at this time section five on risk management there are no changes we feel as though these templates collect the risk arrangements by payer and risk bearing entity well so we're not proposing any changes to these templates they show a seal risk by payer and payer specific risk mitigation strategies risk by paired risk bearing entity by either hospitals and any specific risk mitigation strategies and then a summary of shared savings and losses and some of this information does tie to what's in section four section six is the ACO budget section so this is where we collect the financial data it includes projected and budgeted financial statements an income statement with accountability which I am going to talk about on the next slide variance analysis budgeted sources and uses documentation per member per month revenues by payer details of hospital participation and risk management compensation and population health management expense breakout numbers the budget narrative includes an explanation of significant variations over a prior year and we are basing that off of the revised budget which you heard at the end of May and we're reviewing now and then any expected gains losses their rationale or to the extent applicable how one care intends to balance to break even budget surplus reserves et cetera we added a question here which is underlined or maybe it's a sub question to discuss any prior or current year surplus or losses and their intended use and how they were earned how does non-profit status status effect treatment of reserves so this question sort of links to the certification question about their new non-profit status just a quick an overview of the financial template which you'll see posted are in their own workbook we may keep it that way since there are so many of them instead of being in the master but there are a few little adjustments that we need to make before their formatting adjustments and and formulas that are in the forms before we can call these final but they are substantively correct on the on the website now in in the workbook these are the templates that are included the balance sheet I didn't know here but we did make some updates to the to the account lines the income statement and with accountability we did a lot of work on that with one care this year and we're pretty happy with the result I think it presents the picture of how their business operations work more clearly this the income statement with accountability includes expected total cost of care target components that are processed externally to one care which includes fee for service claims components surcharges etc they're broken out by payer program and total cost of care accountability target so this more this new income statement more clearly shows you their full accountability budget including dollars that are that never flow through one care and then what dollars do flow through one care and we think that that will be clear to the public and also for accountants it more clearly ties to a to a standard income statement but what an account would expect to see is a standard income statement without including all these dollars that don't actually flow through the organization and that went through quite a bit of process work with our finance team and one care finance team to improve that template there's no changes to cash flow the variance analysis is a detailed variance analysis that we added into the guidance last year it was in the question and answer process so it seemed to make sense to just put that in up front sources and uses it really helps to us to understand where the dollars come from and where they go this was updated to clarify and define the the fields and so I think it's a lot more clear this year 6.5 per member per month revenue by payers no change the hospital participation tab is under review though as it stands I I think we can include it as it is we've been working with health systems finance team as well as conversations with hospitals to clarify or to align how this information is collected on the hospital budget side and the ACO side so there are no proposed changes currently but we recognize that there are there's some ways that we could approve this improve this data collection so that we can align and understand how the ACO look maybe different than the look you get from hospitals. 6.7 is ACO management compensation information they're also as Sara Tewsbury said the updated guidance on the interpretive guidance on executive compensation tied to quality is in certification but this template is simply collecting the salaries and then we've updated the population health management expense breakout that covers the changes in section 6. Section 7 quality population health model of care and community integration initiatives has these key areas model care clinical focus areas quality improvement population health and payment reform care coordination and care navigator integration of social services childhood adversity and all-payer model quality and population health goals in reviewing the criteria for these sections and why they're each in here we know that the childhood adversity question is specific to a certification requirement so we move that to certification form that's the major change here and then as I said at the beginning there were some all-payer model quality and population health goals questions that were waived last year that we have reinstated and the narrative should include across these areas progress to date including HSA level statistics where appropriate methods metrics and measuring impact to help us evaluate all these areas and the proposed budget year objective this slide summarizes the data that we collect in this section I added this slide because I think another thing that I pulled from that I heard from the conversation with Michael Baylett is that this section is really the hardest one for us to evaluate and you know he made the recommendation that if we pull in subject matter experts that work on these type of programs and you know we can think about that but we do now collect data and review it and need to understand the scope of what we can collect and and our evaluation of it so I wanted to summarize the data that we currently ask for in the guidance and that includes clinical focus area results as available variation in information on variation in care which in utilization measures by HSA as well as variations in outcomes measures by HSA and the five most prevalent chronic conditions and the five most prevalent high-cost conditions which they broke one care has broken out by payer in prior submissions we also ask them for data on population risk stratification and spend since that is how their care model that's what their care model is based on and we ask them for statistics on care navigator and care coordination so we've made a couple of minor tweaks to questions the model of care question has been updated to read what elements of the care model has one care eliminated or not adopted because they were not successful what elements have been scaled up and where would one care like to put more resources what is the data behind these decisions we ask this question more directly because it seemed to come up in discussions that board members want to understand what programs are being scaled what programs are or may be tested but are not they're not going forward with and you know where would where could more resources go if they were available and why what is the data how are these decisions made clinical focus area question again the quality and clinical focus areas were sort of mushed together in previous guidance we we broke them out and updated this question to read that one care should report any results on 2020 clinical focus areas note interim if they're available and progress to date on 2021 clinical focus areas using the appendix 7.1 provided and they should provide a narrative description of the ACO's implementation strategy for clinical focus areas in the current year and in planning for the budget year and how does the ACO support providers in achieving the goals of the clinical focus area how are results shared with providers at the HSA and or the organization level and does the ACO prepare any final reporting on on these areas section eight there's no change to the section the section was not required last year as I said the third question was in section seven but we moved it to section eight and that question reads all pair model quality and population health goals please complete appendix 8.1 which is ACO activities related to the Vermont all-payer ACO model agreement population health and quality goals and describe results to date and explain your strategies for assisting the state to achieve its quality and population health goals as specified in the all-payer model in doing so please also discuss expected impacts of COVID-19 on 2021 performance sharing early indicators or relevant insights what we did remove from this question was part of the question asked about ranking HSAs against their targets and we took that out because there are no longer HSA level targets but instead we are asking for when I instead we are still asking for the HSA variation information in other areas to cover that okay so that is all part one the reporting requirements in the sections part two is the ACO budget targets this table is provided as a guide and a reference for discussing template 4.3 projected and budgeted trend rates by pair program so in deciding whether to improve or modify an ACO's proposed budget the board will take into consideration the requirements of the all-payer model including the all-payer total cost of care per beneficiary growth target the Medicare total cost of care per beneficiary growth target the ACO scale targets and the statewide health outcomes and quality of care targets per the rule these projections or trends are updated yearly and and we provide that as a reference and Sarah Lindberg will talk about that in more detail when it comes to that in so the budget targets the board generally sets ACO budget targets and benchmarks during the budget submission process after taking into account the ACO's proposed budget so this is is you'll hear about this separately the board may establish guidelines for managing certain portions of the ACO's budget for example admin expense ratio population health ratio that's what I mean when I said the financial templates were being updated we have to make sure those formulas and calculations are in there the technical detail section three or part three sorry of the guidance is guidance around the revised budget process we're putting in here due May 2022 or spring TBD it was presented by the end of May this year but it can be set at the discretion of the board upon execution of the payer contracts we keep in close on tackled one care about that it includes all of these elements one through eight there are there are no changes there are two parts that were in last year's guidance that I moved to reporting that is the details of expansion of fixed perspective payments across payer programs including payment calculation methodologies and adoption rates by providers and actual real opinion and the reason is that those are specific budget order requirements that we do want them to hear about sorry that we do want them to report on but they're specifically moved to our reporting manual to get that information as opposed to the revised budget elements above are sort of the standard budget order elements and number nine are reporting requirements um let's see all right so a note about the monitoring plan so the ACO reporting manual outlines standard reporting other deliverables to be provided by the ACO to the GMCB along with the deadlines for their submission over the years that we've been reviewing the budget we have found that there are standard reports that we want to collect year over year the network development strategy clinical focus areas reporting on the comprehensive payment reform programs for some examples off the top of my head instead of putting those in the guidance every year we have created a separate manual where we're standardizing those reporting templates establishing deadlines for reporting throughout the year and this is will enable the green mount care board to monitor performance against the budget and should allow us to keep reporting requirements in reporting and the budget in the budget um I we are working to get that available for people to review what is in there so that you can see okay if it's not in the guidance it's here and when we're going to get it and staff when we're not actively reviewing the budget are working on compiling and summarizing the reporting that comes throughout the year so that board members can use that can review that information in conjunction with their review of the budget all right so that brings me through the walkthrough again just a reminder of the next steps as Susan mentioned at the beginning after a discussion today there will be a public comment period we ask that written comments are submitted by June 16th so that we have time to review and incorporate those for our potential vote on the 23rd and that brings me to the end of the slide I'm happy to take questions so thank you so much Marissa and Sarah and Marissa I want to compliment you on uh taking to heart um really trying to streamline where possible but without removing any information that's so essential as we monitor this program so thank you for that and I I know that no regulated entity will ever believe anything is streamlined unless it was a simple form with one line and that one line was our our stamp of approval but with that being said I think you have tried to um you know jettison things that aren't necessary and I really appreciate that work and with that I'll open it up to the board for questions or comments one question Marissa great job very thorough and very clear presentation do you have a sense of whether reporting manual might be ready for folks I'm just thinking that might be a question that comes up in public comment yeah um I was hoping to have it for now but we're not quite there I think that it's important for us to be able to post it for the vote or at the very least we have a table of contents which shows which is very detailed and shows each report that's in there the statutory reference the reason for the report a plain language like sort of purpose of what the report is and so I feel confident we can get that posted the reason for the delay is that each template is gets reviewed with one care and some of them are sort of in in draft form and I don't want to be confusing by updating those constantly so we're trying to update them in the order that they're due but I think that if we can get that um that table of contents up there then people will be able to see and that will that will be a huge help so so that you can see it in time for the vote thanks makes sense okay other comments or questions from the board I have one um go ahead Tom the uh so I I haven't set out the uh you know the uh draft of the ACO strategic plan and you know I I was looking at it for in terms of specifics having to do with their their cost reduction they say in the introduction letters that the ACO says turning the tide from an unsustainable model with health care spending on the rise and quality of care stymied to a model that reduces health care costs and then later on their other reference to cost is short term which is good recommendation number 10 from the all-payer model implementation plan identify cost growth drivers that's the narrative and so I kind of jumped from that um in the interim having listened to Michael Baylett who was saying that reducing costs is one of the you know top strategic goals or or you know of a high of a high performing at ACO to just the example here on page 12 of the slides where we're talking about provider contracts payment strategies and methodologies and their contribution to goals of reducing costs and I I guess I'm unclear as to where in these guidelines we are asking the ACO to clearly set forth their goals for reducing costs in some kind of a metric other than a narrative phrase I mean I'm happy with the way things are turning in terms of FPP and that that these guidelines have been amended a bit to kind of circle around um a a a a definition of of what percent of FPP is quote unquote the tipping point that's a good thing but I don't I I don't know where to look to say here is where we are on a cost frontier here is the ACO's hoped for impact on that cost and that as we go down the road we can see the progress going forward well I think that is um that you're right that is in that section um and I guess if you have specific measures in mind that you think that we should add we can look at that um but I think you're right that it's captured in the narrative because beyond those targets we're not collecting data on specific measures so I think we're hoping through some of the narrative or continued discussions to perhaps be able to hone in on what that data could be and then as you know on the target and strategy for increasing fixed perspective payments um the ACO is expected to report on that budget order condition next month um and we have questions in the guidance um on that going forward as well so that I mean that's a good thing because we will have that in time to uh have that as as a um a point relative to um our rate reviews and our hospital budget process but um in terms of cost I I I don't know where to look to figure out what it is we should hold the ACA ACO to um there's no starting metric and no ending metric and um I you know um I think the kind of progress that we're making in terms of defining FPP hopefully we can make some progress in terms of what they mean by goals of reducing cost so I'll just speak for myself in reaction if that's okay Kevin go ahead Robin yeah so where I what I look to for that is two things I look at um the all-pair model uh cost target goals for trend um and then I look at the benchmarks that are set annually for the ACO and I and then what we get for information in terms of their performance in quality and cost so to me I think the most relevant data in terms of the financial data is in those benchmarks because having that is that is the cost goal is the benchmark um the other place that I is in terms of the evidence that they had presented in prior budgets for their care model and whether their care model is achieving the goals so it's not a financial metric but the the purpose behind the care model is to bend that cost curve so um I don't know if that's helpful um for your thinking Tom but I just thought I would share that in terms of how I look at it yeah other questions or comments from the board yeah I have a couple um and Marissa they're actually relevant to the actual guidance the budget guidance so I'm wondering if you might be able to pull that up so I can be more specific sure thing hang on just a sec okay you can let me know what yeah um so actually I wanted to look at section two under question number three that's possible and I want to preface this all with without having seen the new reporting manual some of my questions or comments may be better suited for the reporting manual but as I was reading this I was thinking there's information that I would like to have prior to the budget process you know so if it's coming through the reporting manual great just let me know that okay so in section in question three if you look at B B is talking mostly about you know a description of new or expanded ACO incentives to strengthen primary care including strategies for recruiting primary care providers providing resources to expand capacity and then it goes on to say and reducing the administrative burden of reporting requirements per providers etc etc that feels to me like that session that section on reducing the administrative burden of reporting requirements for providers is relevant not only to primary care practices and primary care providers but to all providers that are participating so I one suggestion would be to yeah cut that and make it make it see and that way it's clear that we're interested in hearing about reducing administrative burden for all providers not just primary care providers if that makes sense yeah make a note okay great and others may weigh in and and decide if that's you know important enough to change or not I also have two suggested additions to that section three or not section three part three of section two it would be if we called it E or now F please quantify the number and type of providers who have dropped out of the network in the past and I suggested two years to the best of your knowledge and to the best of their knowledge your their reasons for exiting I really want to understand providers who participated in the network and now no longer participate in the network and why so something a question there that will help us understand those who have exited and why and how many and what the types of those providers are and then an additional one right below that which would be I would like more information about what kinds of provider outreach formal provider outreach results they have whether it's coming from surveys or focus groups that evaluate satisfaction that providers have with ACO programs so I lost I lost this are you there okay yeah I'm still here I've packed my computer's ability to keep up public editing is probably risky but I'm following you okay great I just want to understand you know how are they assessing you know provider satisfaction with the ACO programs they're evolving all the time so I really want to understand that somewhere so again this may fit more into the reporting manual than into the budget guidance I don't know but those are two areas that I'm really interested in learning more about and I think it relates to network strategy right and our scale targets and things like that that we have to meet and then if you I guess you can't go to section yes go ahead say on that point so I those are great suggestions what I want to do before we incorporate that is review that template in the reporting manual like you said it'd be really helpful for you to be able to see that because if those elements are included and that is you know that satisfies what you're looking for then it may actually be covered already so I will review that and let you know before the vote great I definitely do not like so yeah no interest in duplicating any work just want to make sure it's somewhere between the two sections or the two documents and then section four actually since it's hard for you to pull that up but you could either well I can just tell you it was on slide 16 or it's in section four and it's those new questions that have been added under subsection two okay I'm going to bring the slides back up because the word document crashed well I was no worries it's slide 16 okay this should work fine it just takes a minute okay okay great so under a fair how is the aco using total cost of care data I think it might be helpful to add how is the aco using total cost of care and quality data at the local hsa level to identify high value and low value care since you obviously need cost and quality data to understand high and low value care so I think that might be it's a small addition and then in c letter c what evidence do you have that the aco local accountability strategy is working I was going to have it be a little more specific my suggestion if others like this or not was to say please provide evidence by hsa that the local accountability strategy is working in other words please supply evidence that steps taken in part a and part b above are effective at eliminating waste and improving health outcomes so it's it's much more specific it relates to part a and b and it's by hsa so that was my suggested modification for that section I can go on to my my final comment unless you want to respond to that piece first I don't I don't have any comments here what I'll do is take your suggestions and look at them and see if if anything's captured elsewhere or not and then when we come back let you know and then you know we can propose putting these in and if everyone if all board members agree we can include them in the final sure that sounds great and then I guess my last suggestion was and again this could be in the reporting manual that we haven't seen yet but it relates to the cpr program to me this is you know I don't know whether where it fits but it's a really important pilot in my mind it's really the only way for independent providers to participate in the model or one of the you know it's really an important way for the independence to participate and it's really our opportunity to evaluate how true fixed payment is impacting cost is impacting utilization is impacting population health we need more information about this program and how it's rolling out you know as it relates to participation rates of independent providers as it relates to total cost of care how has that been affected by changing you know independent providers payments to a capitation model how has it affected health outcomes we have several years now in the program so how do we where are we going to see or ask about the assessment of this in a really concrete way so we can better understand whether it's working how it's working you know provider buy-in impact on cost impact on quality so again if it's in the reporting manual great if it's not could it fit in here yeah this is a great point and I think that this is an area that we have the ACL report on through the year so over the past couple of years we have had them do interim and final reporting in july and january at this point it may annually may be appropriate we do not have a standard reporting template for that and this template is actually like next up on the docket for development into you know here's the standard template that we want one care to report every year on this program so that we can understand and evaluate this program over time now that it's well established and an example of a program that's growing so the reason why you don't see it in the guidance is because I do view it as a reporting requirement one that still needs standard reporting so we can if that is a concern we can show you what we what we have or what we propose to do and you can decide if that um is sufficient you're comfortable with that or if you want to add something in the something into the guidance um on that program okay that's great thank you those are my comments suggestions questions thank you Jess other members of the board so I just had a question about one of Jess's suggestion which was the evidence by hsa that the accountability strategy is working because I believe 2020 might have been the first year of that strategy or 2021 now I've I've lost whether it was started this year when 20 yeah so we won't have the 2020 results until when Marissa oh let me see if I get this right um I guess the end of this year somebody can correct me if I'm wrong but I think that yeah there's about a year lag in those results so I'm just wondering Jess if the answer we'll get is we can't give that to you because we're still doing the 2020 results and so would it be better to have the more theoretical question this year and then shift it to a more results oriented question for the timing of the data I don't know I mean you can think about it I was just thinking that like I I I agree we want to understand that but the data lag issue may be a problem for getting that by October is what I was wondering about yeah I mean I guess I wonder if there could be an answer to that question that relates to for example their former risk distribution model where it was actually local hsa accountability I mean are there lessons that they've learned about how strategies that they pursued at the local level that have improved you know cost and quality and what evidence is there about that so maybe we can tweak the language a bit but certainly there has been a look at the hsa level for the past several years and there's data on cost there's data on quality you know what strategies are working and what's the evidence about it so I guess let's maybe we can circle back to a better question here but I don't want to lose I don't want to lose a look at the hsa level about what's working and what's not so how do we incorporate that yeah no I think that makes sense to me I just wanted to make sure that we're asking the question in the way that we get the information that we want and I think one of the my recollection which may be faulty from the previous risk model is the explanation for moving away from it was because of the small ends in some of the hsa's the data wasn't meaningful so I think trying to figure out what the right question is so we can get that is important so sounds good yeah I agree with the spirit of your of your thought okay other questions or comments from the board I'm sorry Marissa did I cut you off well I can make one response to that I think and that the way the new template is it we have we're collecting information back to 18 we we decided we could sort of chunk it all together so you can see the settlement for 18 19 which was the the old risk model and then we have 20 20 21 and 22 which you know the data lag issue is always an issue but I think presenting all of it there whether we have full data or not then then in the narrative perhaps they can refer to well here is what was going on in 18 19 here's what we think for 20 here's what we're thinking about or projecting for 20 21 2022 so I I'd like to hope that in presenting it in that way like that it will allow one kid to sort of discuss that and then I also asked for timelines for when data is expected to be final because it is it's challenging to keep track of that and know where to ask for it and when okay other questions or comments from the board hearing none I'm I'm going to open it up to public comment does any member of the public wish to comment on the presentation today about the proposed guidance for fiscal year 22 aco budget submissions well I'm not seeing any hands raised but I'll just remind everyone that we do have an open public comment period that the full language data of the guidance along with the templates will be posted to our website so that you'll be able to walk through those more carefully and again I want to thank Marissa and Sarah for the ha