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[Music] [Laughter] [Music] well welcome everyone to the oregon nevada chapter fall virtual conference we hope your families are healthy and staying safe a couple housekeeping items we want to remind everybody that towards the end of the session we'll put in the chat box a survey we would love it if you would take the survey it allows us to continue to provide you the education that you want also the following day uh there will be another survey going out of the general conference so it would be great if you could fill that as well our next virtual conference is going to be in january 2021 and we hope to have our first in-person conference in may at salishan so fingers crossed that we'll be able to do it in person conference a special thank you to all of our volunteers for helping us put on the conference it takes a lot of time and effort so thank you very much if anyone is interested in volunteering please feel free to reach out in the chat box we would love to have you help us out a special our keynote speaker for this session is key bank key bank is one of the nation's largest bank-based financial service companies making it easy for you to bank anywhere they're committed to helping their clients and communities thrive and to that that means doing business fairly responsibility rep promoting diversity inclusion and making meaningful investments in places where people live and work thank you key bank for your ongoing support of the oregon chapter we appreciate it this session is health care updates by andy easton and rebecca thiel a little bit about them is andy easton has a long tenure in healthcare issues and polit policies she currently serves as vice president of the government affairs of the oregon association of hospitals and health systems in this position she manages lot manages lobbying teams of oah hs and engages members and grassroot activities in salem and washington dc after growing up in idaho and he graduated from the oregon state university with a degree in health care administration she and her husband are raising their daughter who has a birthday coming up and she is already her daughter is already showing strong independent leadership leadership styles in 2010 andy was the recipient of the portland business journals 40 under 40. in 2019 the portland business journal recognized her as an influencer in the legislation rebecca is the director of public policy of the oregon association of health of hospitals and health systems she's responsible for management of member-driven public policy development and related to the state and national health policy including delivery system transformation addressing affordability and value hospital community benefit and public health policy rebecca currently serves as chair of the state's public health advisory board prior to her role rebecca worked as a health promotion of chronic disease prevention policy specialist in the oregon public health division welcome andy and rebecca we're happy that you could join us today great thank you i am going to go ahead and share my screen well good morning everyone thank you again for inviting rebecca and myself to join you on your virtual web webinar today we're going to give you an update of what's happening in the political arena and some of the policy updates that we will share are ones that we have talked about in the past with with many of you and many of you have participated in the kind of the fine edging of rule making with us but we want to make sure everyone has an update on those as well as you can see rebecca and i are both still working remotely and so we welcome you into our homes this morning please enjoy yourself grab a cup of coffee tea water as we go along we hope to have a very engaging conversation with you so our goal is to kind of lay the political land of what we anticipate happening in the next legislative session as a result of what a unprecedented year this has been and that will include talking a little bit about the elections and how the legislature will operate in the upcoming session and then i'm going to turn it over to rebecca who's going to talk about the implementations of senate bill 889 the healthcare growth target as well as house bill 3076 the community benefits so framing this year this has really been an unprecedented year set by force very significant um events that have influenced all of us from the national level to the state to a community and then to a personal level this includes an unfinished 2020 legislative session due to a republican walkout over political infighting a covid19 pandemic that occurred less than you know two weeks after the session ended and then a nationwide um which also sparked a lot of protest here in portland as a result of the killing of george floyd and then in august september we had some really devastating statewide wildfires that caused significant harm and destruction to many of our communities so example of how this these four major significant events are in influencing the oregon way or what i like to say how organ is like a pioneer in many many different aspects is that in the in the wildfire case a lot of the traditional platforms that we've seen on the national level with politics and infighting there has been done via tweet and we actually saw some of that transpire here more at a local level between the governor and republicans over the wildfires and there was some misunderstanding and you know it is also an election year so we have to take that into consideration too but the governor essentially blamed um or sent the sense out there that she was blaming the republicans for the wildfires this is not normal organ traditional politics this is a very new way of doing politics in oregon and so we're beginning to question whether or not the oregon way is changing to more reflect of the national level we've also seen in the last 18 months that the the senate republicans have walked out three times they did so in the 2019 session on two times with um vaccines and guns and climate was their first walkout the second walkout was on climate and then the house republicans joined them on the third time they walked out in the 2020 session which closed that 2020 session early because of the climate build that was out so we had those walkouts one of which completed and closed down the 2020 session and we've had two special sessions since then uh the two special sessions the first one was in really a response to the public outcry that we have seen with the continued systemic racism and the killing of george floyd in the need to have some police reform but it also was an opportunity for the state to look at some potential response to covet 19 and if there were any significant rules that needed to be addressed to respond to that the second special session really was focused more on um how do we address the budget how because we weren't able to rebalance the budget in the 20 and 20 session we had to find a way to really adjust that budget and close the 1.2 billion dollar budget gap that had occurred as a result of covet 19. that special session adjourned in august weeks later wildfires started up the governor then sent a note out to leadership without negotiating with leadership in advance that she was going to line item veto some of the budget pieces that were passed in that second special session [Music] by doing so she triggered an internal fight between the leadership senate senate president and the speaker of the house for not um giving them enough heads up have noticed that this was the action that she was going to do so that line item vote veto really has sparked some internal disagreements and struggles i think between the presiding officers and we are anticipating a third special session likely after the elections but before thanksgiving to address any additional budget needs that need to come out for wildfires or for covet as we go into the flu season but also perhaps looking at some housing and other housing issues and other regulatory issues that need to be addressed because of the wildfires the impacts that covet has had on the state so far really have been around public health measures government oversight in really setting some unprecedented ways the flexibility that the governor has in as being governor in a state of emergency when it's been declared she can um make some executive orders in which she did including um one that restricted some non-urgent procedures to by hospitals and other ambulatory surgical centers she limited the the commerce of the state so limited how and where and how many folks could gather in social gatherings recently we did a statewide face covering requirement that has been more enforced more emphasized i guess in the recent weeks and then we've we've seen a lot of moving to online and remote work i know our association in the clackamas county area we are still closed and we anticipate that we will be working remotely for until the beginning of the year at schools majority of our schools are also working remotely and that has had some significant impacts on on our workforce so the other the other issue here that we want to highlight is the continued inconsistent uh national strategy and alignment as we try to move forward in containing covid covid19 and knowing that going into the flu season so the impacts that covet has had on the legislature itself it really has limited our ability to engage with legislators as well as to have access to the public capitol building the building itself is closed it's open to legislators on a limited basis as well as some select staff but when we go into special sessions e-board it really is limited to how we can engage and so we've been doing most of our work via remotely such as using zoom platform teams platform is another one that the the state has been using and by doing this it really restricts kind of that that public input that really makes oregon government um as strong as it is and it also creates some frustration with the lack of process and transparency by those who want to be more engaged and so what we're beginning to see is that because the lack of transparency and inclusion is happening the minority leader in both the house and the senate feels like they are being excluded from some of the significant conversations that are happening and then the rank and file both of the majority and the minority in the house and the senate really aren't sure what's going on they're also not being convened to be told okay here is what we're going to do and so there's a lot of frustration that that they don't have the opportunity to represent their constituents to the full capacity that they would like to we've also seen an elevated role in the emergency board often referred to the e-board the emergency board is a constitutional group that meets during of legislators it's bipartisan bicameral they meet during the interim so in between our sessions to really maintain a check and balances on the budget to make sure the budget stays afloat and if there needs to be appropriated additional funds to certain areas for projects etc they can they have the authority to do that what we've seen in the last eight months is that that e-board has also become a place of where some policy has been made and then re-pushed out through additional funding requirements so they've taken a different role on and they are saying leadership is saying that this e-board should be used this way i think others in the minority are saying no it shouldn't be used that way it should be if you're going to do policy changes of substance that needs to happen through a special session where all legislators can weigh in so we know this is an election year i we we have to talk about it a little bit we'll try not to get into too much of the the political weeds and and you know one side over the other on this i come from a very political house where my husband and i both are involved in in politics so we respect and we understand the sensitivity of this this issue but we do think it's important to kind of lay out what we are seeing as it will impact or could impact the work that all of us do so it's really a tale of kind of two elections one a federal and then one estate if we look at the presidential election which is at the top of our ticket on top of our ballot we know that the president's approval ratings prior to covid were you know fairly good they were near and hovering over 50 which is not a bad place for a president to be going into an election of course personally they would always like to be higher but percent is not a bad spot to start in covid hit we saw the campaign begin to shift the dynamics of of copid the lack of a strong public health message and frankly the lack of i think him at following the message that he was sending out combined with the social unrest of the killing of george floyd really started to um unravel his uh favorability in his approval ratings and what we are seeing now is that the president is hovering very in the low 40s of their his approval which has allowed for the the democrats the biden harris ticket to really kind of ramp up and polling suggests nationally that biden leads substantially by double digits in many of the states if not at nationally at a whole and at the battlegrounds that we'll talk about here in a little bit he is he's gaining some extra support you know he's focusing in on suburban women seniors but just general turnout and making sure that people get the vote out feel like they can mail in their ballots without feeling that they are being hurt and then the president is not doing that he is he has a different approach um that he has taken on and and so we'll see we are in the final two weeks less than two weeks of the of the election a lot can happen between now and then you know we our votes that you and i all make are part of the populist vote we also have the elector electoral college vote and they just the electoral college is a long standing it's based in our constitution it's a temporary group of electorates who who are chosen to represent a state um for for voting purposes each state is allocated the same equivalent number of what they are represented in dc so oregon is represented by seven five members of the house and two senators so we have seven electoral votes um they will vote usually representing the the state as a whole um in their vote the total of um electoral college voters is 538. you need 270 to become president so what we will see and what we could see i mean the the current uh cook's latest scenario which is a fairly relied upon group they show biden up you know 20 percent or 20 points higher than what is needed and so that's kind of where we're going into this election anything can still happen it is likely it is possible anything is possible between now and november 3rd that things change another october surprise happens some of the toss-up states if not all the toss-up states go trump and maybe one or two three of the leaning democrat states move over to support trump and he has he has enough to take that presidency again so a lot can still happen in these last remaining weeks but what we are seeing is a huge increase of early voting states that have already sent out their ballots people are voting and they're returning those votes earlier than we have seen in historical races so if we look at congress house of representatives we do not anticipate there being any significant change in the house of representatives democrats will likely remain that control they may pick up a few they may lose a few but in general they should stay around that 230 234 seats on the senate and the senate is really the the chamber to watch right now there are more seats up for grabs per se that that are in a battling grounds that both republicans and democrats are either going to try to protect or try to gain so we could easily see at the end of the day on november 3rd or 4th that there is a split or a 50 50 senate and or it could be a 54 uh republican lead or it could be a 51 democrat lead i mean there's still a lot of numbers in play in a little in a lot of ill unpredictability in many of those states so the elections are going to be important for a couple of reasons right now the senate of judiciary comm ttee and i think in just a few hours we'll be putting forth the recommendation of amy con connie barrett um for the supreme court they will make that vote likely today and then it will go to the full senate for further confirmation we have heard and i pretty publicly that the senate ds are likely not to show up and provide quorum for that final vote therefore suspending the nomination of judge barrett until after the elections depending on what happens um the supreme court does not need that seat field to continue with its decision making so what we should anticipate happening in the next couple of weeks or months is the court meeting and discussing the future of the accountability act we know that with under president trump he continues to pick away at what the accounting accountability act does um and and so those those elements of it are still in the hands of the supreme court at this time if the democrats run the table meaning they are they have the majority in the house the senate and in the white house we will likely see some really strong efforts to restore the the trump accountability act cuts and expand coverage there will also be a debate over medicare for all and then we'll see a shift in the decisions on how do we address our deficit and what do that what does that reduction look like so we'll we will have those conversations should the democrats take control if the republican party keeps the white house and the senate we will have further repeal and replace of the aca and other potential initiatives and then we will have major deficit reduction effort with the focus being changes and cuts to the medicare and medicaid plans so what do the elections look like here in oregon bringing it closer to home the house currently um has a super majority so does the senate where the democrats lead 38 to 22 and how the senate is 18 democrats to 12 republicans there so the supermajority allows for the house or the senate to take votes on taxes without the need of a member of the other side of the aisle to support it what it doesn't give the parties and where they would like to go is quorum proof majorities so in the house and in the senate they have to have two-thirds of the the chamber to be present to start a quorum and that is to engage in doing business of the of the various chambers so the house democrats are looking at picking up two seats and same with the senate democrats to get that quorum proof which would prevent walkouts by the minority party to stop legislation the republicans on the other side of the coin are really kind of fighting to restore balance they are using messages that politics is local look and see what has happened under the leadership of democrats they've increased your taxes let's try to bring it back home and restore some type of balance and for them a win of one two or three seats would be a significant win for them the democrats message is really focusing more at the the national impact and how can they tie their republican opponents to dem or to president trump all of the house seats are up and uh about half plus one of the senate seeds are up for election senate seats are every four years houses every two years so we have 76 legislative races in state going on plus if you look at the top of our ballot we have secretary of state also in a in a race too so the competitive races are pretty limited um there's really a really strong focus on what are those battleground districts and those currently and this is true for both house and senate it's salem bend central and north coast are the ones that both the republicans and the democrats are focused in on in either maintaining keeping those seats such as in band house republican representative helt is in a very strong position to try to retain her seat but she's out if you look at the registration numbers um the registration numbers for democrats supersedes that of republicans so she is really trying her hardest to maintain that seat whereas the the democrats in that position really want that seat it's important for republicans to hold that seat because if they lose that seat then they they lose they allow the democrats to get closer to that super super majority or that quorum proof number and then we've had a huge departure of some of our longtime more moderate democrats and republicans that have really opened up an opportunity for others to come in and potentially either shift the ballot to the republican side or or to a more democratic part party so these emerging issues will all be impacted by what happens in in salem and in dc we anticipate that we will see quite a few issues in the 2020 session come back from the 2020 session that were just not addressed because of the walkout but if we look at some of the um what some of the other issues going into session we could see a few of them addressed first in our third special session which is likely again to happen after the elections and before thanksgiving with the focus on wildfires response and the housing issue during covid we as an association along with our partners at the oregon medical association would love to see medical liability protections put forth in a third special session right now many of our providers are are at risk because of some of the the um the decisions that the governor put out there right decisions around limiting certain procedures during our first spike of covid but because of that many of our patients weren't able to get the services that they needed so we would like to have medical protections extended to them we saw a good portion of other states do that and we would we're hoping that we can either do that in this third special session if not maybe leading into a key priority for the the 21 session and we also know that our presiding officers so the the senate president as well as the speaker of the house are working to increase the participation and transparency of the legislative process they'll probably do this as a test run in the third special session but that is yet to be decided and i think it might be a little too ambitious for for us to think that they will open up the capital for the third special session even if it is slightly modified opening up we anticipate that the first portion of the 21 session will be done virtually partially partially virtually might be might be there i think that is a wishful thinking frankly at this point just knowing that we will still be without a vaccine for covet at that time and we will be at the end of the flu season you know i hope to be wrong but i think our numbers are still going to be fairly high and going into a partial virtual might be difficult but it is important for legislators that we try to get back to normal process as quickly as we can we have heard that the senate president and the speaker of the house really want to normalize the 21 session even if it is virtually by maintaining certain dates and deadlines that they have already passed and put into their their chamber rules so we'll follow those the challenge they're going to have is how do you engage the public to provide their input and how do you engage that dialogue that happens on a daily basis in a more face-to-face meeting that or even floor session that is critical to the creation of many of the bills that end up being passed we've asked our presiding officers if they are going to limit the number of bills they are not so legislators have kind of that open pin to write and draft and request drafts of as many bills as they so choose many of the rank and file believe that that is not appropriate and that should be limited to a very specific number three five maybe at most per legislator and then additional kind of number setting for the committees this is similar to how they run the short sessions but in long sessions they tend to give them an open checkbook of how they how many bills they can be introduced the speaker did tell us in a meeting that we had with her that she's really going to rely on her committee chairs to really focus and kind of narrow down their bills that they hear during a committee because committees will need to be if we're virtual we'll need to be online and the hearings will need to be a little bit more condensed in time so that's where they're going to look at how they can condense the number of bills that are heard versus the actual limitation of the bill numbers now are the themes that we anticipate seeing kind of the overarching themes for the whole session is really going to be budget driven we know that measure 108 and i hope you all vote for measure 108 is a first step in really addressing the the health authorities in the medicaid budget gap that is coming um it won't be enough and we know that the gap will still be there within the medicaid program but it does help definitely shrink that gap and the reason why it won't completely fill it is two factors one we have seen about a ten percent increase in the oregon health plan since covet hit and our economy has gone down but the other factor is we're in a type of recession and usually tobacco users re reduce or stop using tobacco which is a very good thing but the number of tobacco funds that have come in under the existing tax and what would be applied to the um when when measure 108 passes has definitely reduced so there is a gap there that would still need to be funded how that will be funded is yet to be determined i anticipate that the governor's really recently appointed racial justice council will have its have its fingers in that conversation as well this group is a group of multidisciplinary individuals from across many different spectrums really focused in on how we can break down the the inequities and disparities across the various um institutional uh pieces of our budget but also of our policies such as criminal justice health care and education are ones that i know they're going to be focusing on so they will be part of these conversations and how we address that i also anticipate that every piece of policy that comes across will be viewed through a lens of how how is this going to improve equity and improve you know remove disparities in our state and then the other main theme that the legislature will take up is covet 19 in the wildfires how we responded as a state did are there any lessons learned that we should be taking forward and then what does our recovery look like how do we help move oregon forward to that recovery state the health care committee issues that we've seen and anticipate being kind of their their biggest bucket of work rebecca will talk about here shortly senate bill 889 but we know that work group continues to meet they will likely have a product that will need to have some legislation around it to implement it we have heard from various sources that both primary care access to primary care universal care and public option are of top of interest for individuals to have that discussion how do we modernize public health this is a little bit in response to covid 19 but also picking up the couple of works that we've done the last couple of sessions to really monetize public health how do we control and contain prescription drug drug costs there are many proposals out there on that balance billing this one is an expansion of the current balance billing bill or law that's in place one the sunset of the kind of the mechanism that is used the method that is used to determine the the out-of-network rate expires at the end of 21. so we need to look at that but also it expands the application of the bill to include emergency out of network and non-emergency out of network for facilities so hospitals would have to start um limiting their billing to what is uh not built limiting their billing um under under this proposal so we're working on that we're in part of conversations with the agency that is proposing this but also with many of the proponents and opponents and how to make that work and then equity in healthcare we've talked about this in the previous slide but where we anticipate the healthcare committees to really focus in on is how can we reduce language barriers when it comes to the healthcare setting and how do we improve and increase the retention and recruiting of provider diversity in this state so we also know that there have been some changes to rules that have really been helpful to many of our providers and patients during covid and so there will be conversations about how do we how do we capture that make permanent changes especially around telehealth we have heard from our members that telehealth has been a huge has has seen very much positive reinforcement by patients they really like that and so we will look at how we can increase that parity and this access to telehealth across the state nurse staffing we anticipate that there will be some changes to the nurse staffing law especially in how a committee meets during a public health crisis the vaccine laws this is one where the association has been pretty out front in and encouraging and would love to see a mandate on vaccines for folks not just related to covid but beyond that and then how does the state be better prepared for an emergency so there is conversation around ppe stockpiles how does the state become a better purchaser on that and then the model that we currently have is that the right model for emergency preparedness i think that will be in question in conversations around there too medical liability the whole medical community will continue to push for medical liability as it relates to covid and then the health authorities agenda they're really going to be the top of their agenda is really putting more emphasis in their 10-year strategic plan focus on health equity so they will be coming from every policy with this angle leading that charge and and so it'll be will be part of those conversations we look forward to those conversations and in really understanding how they are going to achieve this goal and then behavioral health we continue to you know invest and then de-invest in in our behavioral health programs so i think there will be some really strong and um broad conversations around how do we continue to invest in our workforce so looking at the workforce versus the actual programs and services and how can we [Music] ensure that patients are getting the right access to care at the right time so that's that simplifying access so making sure that regardless of where the patient is or regardless where the individual is they they can figure out how to enter into the behavioral health system the medicaid budget we talked a little bit about already this is one where we have seen the health plan numbers have increased 10 percent because of the effects of covid that really was because of the decline of employment and then we continue to see and we will likely continue to see this grow over the next several months and so that that is one that we continue to watch very carefully rebecca will talk about senate bill 889 and the healthcare growth target but that is a a focus point for the the health authority they will be the oversight agency for that program as it continues to be developed and then we'll also have conversation around lessons learned in covid and i would almost say this is going to be lessons learned covid plus the natural the wildlife fires because what we saw during covet is was that there was really it really highlighted some of the inequities in our state and in the health care system but also we saw where our financial system around payment for services well frankly it was it was hurt during certain um aspects of the covid19 um when when we had executive orders that limited our ability to um perform elective and non-urgent procedures so is there a way to help protect hospitals as a safety net during another in a future pandemic but also how do we respond as a state and as a health care system for future and also dueling uh emergencies so you know when we had we were pretty going we were going in a pretty good rhythm with covid through the summer and we were i think really understanding what it means to be operating in covet and then the wildfires hit and there seemed to be a disconnect between the public health role during covet in the fires the hospital role during that t me and then the state's emergency response role during that time so really understanding those lanes as we go forward is going to be critical so i will pause here and if there are questions i'm happy to answer them if not i can turn this over to rebecca for the outcomes of politics the policy side all right well i'm not seeing any questions in the the question box so i will stop sharing my slide and turn it over to you rebecca great thank you andy let me try to get this cute up here um are you folks able to see my screen yes okay excellent all right well as andy said i'm gonna be talking about um two different um policies that were passed in recent sessions um that are really coming up on implementation starting in 2021 that will have sort of broad impacts not only for hospitals but for the health care industry as a whole so the the first one i'm going to talk about is the healthcare cost growth target program um this was uh coming out of senate bill 889 which was passed during the 2019 legislative session um which was actually um the result of a task force which met in a previous session which was senate bill 419 really the the intention of this program is um is to really be multi-payer and multi-provider there have been previous attempts around containing and controlling healthcare costs that were really focused on specific sectors there's been policy concepts floated around hospital rate setting commissions and other other um uh specific sector uh uh target uh programs and and the recognition was that if you sort of squeeze the balloon on one end um costs will sort of pop out in the other and so the intention and policy goal around senate bill 889 is to really have um multi-payer multi-provider all under one common goal one common target and we'll talk a little bit about what that is and really relying on transparency and public reporting and public process as sort of the mechanism for getting getting everybody aligned around controlling healthcare costs together with a total cost of care approach so not necessarily focused just on hospitals not focused just on specialists or pharmacy but really giving folks a goal giving a target and then seeing what people can do to achieve that target and so where the um where this policy is being developed the senate bill 889 created an implementation committee that has been meeting um actually since november of 2019. so they they've been meeting for over a year now um they took a pause during covet 19 so they took a several month pause on the spring and early summer and re restarted their efforts um sort of late summer so that's pushed them back a little bit and they're it's feeling a little a little rushed but they are continuing to meet um and they have two more meetings through the end of this calendar year um but i'll go through some of the decisions that they've made so far and the decisions that they have sort of yet to make going into next year but this is sort of the first thing that they landed on so what is the healthcare cost growth target um it may not be a surprise to you that they landed on 3.4 percent for some reason and that's that's where things land in oregon but they looked at a lot of different factors they looked at historical gross domestic product historical median wage and they really landed on the first five years of this would be a 3.4 percent growth target there would be sort of a check-in point tbd about what that check-in point would look like in 2025 some type of advisory committee or body would come together to see how things are going see where things are going with wages and gross domestic product in the economy but the intention would be that the the five years after that so 2026 through 2030 the target would go down to 3 percent and so that helps sort uh of things down a little bit and so that's that's what they're where they landed and that is the recommendation of the implementation committee so where does that 3.4 target apply so these are the different levels of which it will be measured and so one is just the statewide target total cost of care did the state as a whole meet the 3.4 percent below that is what they're calling for the market level and so this is looking at medicare medicaid and commercial on their own and seeing if at the market level if the 3.4 was met and this would be the state that analyzes this using a variety of methods but mostly looking at the all parasol claims database as one of the main points of um source for data below that is really at the insurer level and so you'll see underneath the three sort of markets how they're defining and looking at insurer level and then below that is at the provider level and we'll talk a little bit about what what the provider level means so this is the criteria for reporting by pair and provider performance and so the implementation committee is still working on some of these definitions um still trying to understand what the difference is between sort of being in the reporting program and reporting your total medical expenditures but then also being accountable there's sort of this recognition of size that um you may need to be a specific size in order to be able to be accountable to uh this 3.4 percent and so as you can see here when you break down that provider level so the difference between this slide where we're looking at the bottom um and this slide is really then what are the providers that are in that level so health systems hospitals medical groups ipas acos um and so anyone in the green right now is proposed to be accountable to the 3.4 percent at some level so being in the public reports um you'll see the blue right now is not not accountable um i think we have some questions around um you know pharmacy in particular not necessarily being accountable we know that that's a leading cost driver and we continue to talk about that and bring that up in public meetings and you'll see there underneath hospitals and medical groups there's a reference to primary care providers in some level needing some level of attribution or volume around primary care providers in order to make things measurable so we we continue to have questions about this um and we'll we'll learn more as the implementation committee makes their final recommendations um not only on sort of the pharmacy being in blue but also post acute providers as well as sort of the freestanding ancillary providers so i mean again these slides that have the health authority logo on them are from public meetings and i can point you to or we can provide a link to where all of the slides have been from the implementation committee so you can sort of dig deeper if you're interested um this gets a little bit to the beginning of their conversations around criteria for who would be accountable so providers who meet the criteria for data submission um you know only pairs and tpas that submit data would would be in this program i think where we're sort of trying to understand more is that third line right there around entities with at least 10 000 unique lives or 5 000 unique lives that live under one line of business so you know i still we still don't necessarily have a sense of who falls into that especially i'm thinking about at a hospital level um but you know five thousand lives could under one line of business could could eliminate or not um you know i think they need to the health authority needs to do some work to talk about how this who would be excluded and who would be included in this um and so there's some work that they need to do around that um we're going to talk on the next slide about how this program has been modeled after massachusetts and i think one thing that we're finding in comparing oregon to massachusetts is we have very different markets we have some very small pride reserve a lot of local payers and when you look at a market like massachusetts where it's really the big national players and and pretty big system pretty big health systems massachusetts has four critical access hospitals and so just very different um a lot of their their hospitals are affiliated with the academic medical centers and so um i think going through this implementation committee process is really highlighting some of the unique aspects of oregon and so the program is needing to be tailored to that so speaking of massachusetts one thing that we're going to see in this upcoming legislative session so is around enforcement so senate bill 889 gives the health authority the statutory ability to do data collection and public reporting but they don't have any authority right now around enforcement or any sort of mechanism for sort of requiring payers and providers to perform under the 3.4 percent or be accountable to it so we anticipate a legislative concept coming from the health authority in 2021 it will be one thing that it will be one of the important pieces of our agenda per session to respond to that but to get a sense of what the enforcement looks like in massachusetts it's really a three-step protocol so the the first step is again this is public reporting so entities who miss the benchmark are sort of flagged they're on the naughty list you know if you're nice and you're naughty listen for like christmas they're put in a public report public hearing you know these entities missed the benchmark um the second part of the protocol is the health policy commission so that's that's hpc that would be equivalent to you know the state agency that that owns this so the oha um conducts a deeper data review of to why they've missed the benchmark so they would use their own data they can request data from the entity they look at pricing patterns utilization payer mix population served and any other factors that may have contributed to them missing the benchmark that may have been out of their control and so what they've seen for those that have missed the benchmark it's it's usually something out of the control so they use the example a lot of when hepatitis c drugs came onto the market that were hundreds of thousands of dollars per treatment that impacted the ability of entities to meet the benchmark so if if an entity sort of fails the step two the data review and there's no justifiable reason out of their control why they missed the benchmark they would be put on what's called a performance improvement plan a performance improvement plan is really a sort of agreement between the state agency and the entity of what they're going to be doing in the next year to get to being under the benchmark and it really opens up their books a little bit more it gives a little more regulatory oversight over that specific entity but the note here in red is not to date no entity has been put on a performance improvement plan massachusetts has had this program since 2012 and everybody who has missed the benchmark has then sort of passed the data review section of this and so i think the health authority when they're looking at what their legislative concept is going to be is really interested in finding an enforcement tool or mechanism that sort of is in between two and three so what what can they what can they pull or what what's some sort of mechanism that they can um use that isn't quite a performance improvement plan but something that's beyond just the data review and the like okay you're good to go so we're really keeping an eye out for that because um we keep hearing them sort of talk about they want some sort of additional mechanisms but we have not yet heard what those policy concepts are so the benchmark committee has two more meetings one in november and one in december so we'll be really tuned into those so that can inform our work going into the 21 legislative session and my final slide on senate bill 889 is this sort of recent tie to value based payment so in the last couple of meetings that they've had particularly after covert 19 recognizing that the fee-for-service system sort of failed failed in a in the covert 19 world where when volume just totally drops um finances are really volatile and so part of that conversation was you know if we're in a situation again where there's you know public health emergency or elective procedures are being turned on and off um that really leads to you know sort of blowing through any sort of benchmark because there's there's that instability and so the conversation around tie the value-based payment has come up stronger this year than we've sort of heard before and one thing on our end from the hospital association is um we've been hearing around you know different value-based payment policy conversations um in several different parts of the health authority and in the state so with our cco's with cco 2.0 pebb and oweb and now with this cost growth target there's a lot of primary care payment reform initiatives happening and so we in all of our sort of public meetings and comments is just strive for alignment alignment alignment we need these um we need these plans and policies to be headed in one direction together and the health authority needs to really take that the lead on that um because if we're going to go down sort of disparate paths towards value in these different areas with different metrics and different reporting systems um we're no better off than we are today and i know it's for service environment with all these different metrics um and so we will continue to to strive for that and push for that and the health authority will be convening stakeholders around a concept around sort of a voluntary compact and so we'll be engaged in those conversations um before we move on to community benefit i think i'll pause here because that's a totally different topic and see if there are any questions there might have been one in the chat i can't quite see the chat from my um angles are there any questions question was i was showing the wrong thing there we go does that screen look better perfect yes okay thank you okay well now you got you got to see my notes which is great all right let's move on to community benefit okay thanks for the screen adjustment i know that's always hard to see where we're at so community benefit um this bill hospital 3076 was passed during the 2019 legislative session and it was a pretty broad bill that changed quite a bit around not only community benefit in oregon but also financial assistance the sort of bullets here are what what the whole bill was about and i think i actually came last year to the benson hotel and we had a presentation around the financial assistance policy requirements and the debt collection practices and provisions that all went into effect the beginning of this year and so today we're going to talk specifically about the community benefit spending floor requirements of it as well as the clinic and facility reporting so if you have the bill if you're handy on your desk it's section six and seven and we'll talk about what those are so um section six of house bill 3076 is around this concept of a community benefits spending floor program um this was the result of several different sessions around some stakeholder communities wanting to bring more transparency around hospital community benefit demonstrated charitable purpose for nonprofit status really coming from a couple different angles one is around sort of the tech county tax assessors and the other is around um you know people that represent organizations from consumer perspectives as well as um unions and so after a couple different sessions um helpful 3076 is sort of where we were at negotiated um in terms of a program and so what is in statute is that every two years the health authority will set a community benefits spending floor for hospitals and clinics um the health authority must consult with hospitals and provide an opportunity to respond to that floor so we'll talk a little bit about what that process looks like and then there must be options for reporting depending on how you're arranged with your clinics um section seven this is sort of the response to the need to the um advocacy efforts around the tax assessors is around um an annual report so this is separate from the spending floor where you'll submit to the health authority that the address of each affiliated healthcare facility and clinic whether your hospita 's financial assistance policy applies and the non-profit status of those affiliated facilities and clinics and i'll just um note that we're still in the process of rule making for section six and seven so we don't have um we are close but we don't have the final documents on what this program will look like um there's still a public comment period that's open around this and so things could be things could change things could be tweaked um but we should have that soon and we'll talk a little bit about that next but in terms of um the spending floor program um it allows hospitals to sort of choose the grouping of which you want to be entering the program with so you could go into the program as just your hospital hospital with your clinic the hospital plus a group of clinics the definition of health system in here is really looking at how clinics are under common control or ownership of a hospital um and so in the current draft of the rules there's um these listed scenarios as well as some additional scenarios um that are listed and so when the um sort of final rules are are written um hospitals and health systems will have the choice to choose how they want to enter the program i mean you can you have to make that choice and you do that for the two years and then you can change it but that's what's what's sort of unique about this um a spending war program is community benefit historically and traditionally has been really just at that hospital level you know specifically for responding to the irs for nonprofit status and so this really brings that view of what what are we doing as a system and at the community level for community benefit and if your clinics are contributing to community benefit in any way or are counted in your community benefit in any way then they're a part of the spending floor program and so going into what the actual methodology is i'm not going to i'm going to show you the principles and then the actual formula here but i'm not going to go into all the detail of it um but these are the principles that the health authority and the rules advisory committee um sort of went into the development of this and so you know comprehensive all 10 community benefit categories and oregon statute including charity care and medicaid are included in this and so we are really looking at community benefit as a whole um the the spending for amount is prospective so you will know what your dollar amount is going into the start of the fiscal year that you'll start to have to like measure for this you will know what that is it's not this sort of retrospective look back and did you meet something or not you will have an actual dollar amount assigned to you at the beginning of your fiscal year and you will have two years to spend up to that amount um we're using and building upon existing reporting systems so if you're familiar with your teams that that implement this the community benefit it's the cbr1 and the fr3 that's your committee benefit reports and your audited financial reports we anticipate that there will be some changes to those forms we really pushed for that to not happen necessarily during the rule making process but we anticipate that the health authority will convene a sort of smaller stakeholder group of technical experts and those that actually do these reports to make some changes to them but um no new reporting will be required for the spending floor program and then the other principle is that it's really objective and transparent and what's meant by that is that hospitals should be able to calculate the formula on their own it's not something that oha does in a black box and spits out a number so if you're using this formula you should be able to get the same exact number that the health authority comes up i'm using the formula and all of the data fields have common definitions and so that's something that we're pleased to see with so again those of you that are involved in the rulemaking and have been working with on this should have this formula and should have been able to sort of run it and check your numbers how this is going to happen in the rural processes this methodology is actually an appendix to the formal administrative rule so the actual formula is not going to be in rule which is good because it gives the opportunity for sort of changes or tweaks that may need to happen without opening up a formal rule-making process but you'll see here it's really looking at you know across several years so you're doing sort of a look back three year average of your unreimbursed care plus your direct spending and so there's a definition of what direct spending is sort of everything else that's not charity care and unreimbursed care time there's a multiplier that looks at your operating margin and that really sort of spits out a number and then your year two is looking at the same number that you had in your one times um your four-year average change in in that patient revenue and one thing that we got clarity on was um that year two this is it's like year one and year two and we're done and then everything will reset again for the next year one and year two so you're never going to see that times average change in that patient revenue over and over and over and go up so it's a two year standalone and then we reset everything the next two years in terms of modeling and what this has sort of shaked out um oha and we the association took the formula and ran it using past data so again it's not it's not the number that you're going to get in the beginning of 2021 um but it's um just a model and we found that 13 hospitals did not meet what would have been their floor and it ranged from you know 143 thousand dollars all the way up to 15 million missing it um our assessment and talking with folks is you know four of those would have likely met the spending floor if they went in at the system level which is with the opportunity was that i talked about at the beginning where you can go in with your clinics you can go in with all your hospitals together we know that big systems sometimes put emphasis on spending in certain communities that have certain community needs and that may look like one hospital it has less community benefit spending and another has a ton of community benefits spending and then that sort of gets equalized out over your multi-hospital system and so that would be helpful in this case here and then in talking you know one-on-one with some of the hospitals that did miss this um many are have identified historical under-reporting um and that has sort of messed up the model like just totally missing categories of reporting some years or there may have been a change in in you know one of the years of who's doing um your reporting and so there's some inaccuracies and some under reporting and you know there's an opportunity when we go through this process to be able to adjust and change and make sure that you're accurately reporting in your you're using best practices to capture everything that you can and so um i think everyone who's in that situation that i've talked to um has has contacted the health authority and has talked with them about that um and so i'm at this point everyone who has missed in the model the floor has had the opportunity to talk with us and talk with the health authority and so i think everybody is pretty ready to go for next year in terms of strategies for you know capturing reporting and this is my last slide just next steps like i said the rules will be finalized in the coming weeks the program begins january 1 but it's based off of your fiscal year so if your fiscal year ends in the end of 2021 you know this program doesn't start for you for quite a while if your fiscal year there's a few few hospitals that have a fiscal year that's in march um you're going to be starting this program pretty quickly here and so with that i will open it up for questions i saw something blinking so i'm assuming there's a question somewhere or maybe i'm talking too fast and see if i can pull that up okay um for multi-state health plans is oha considering total spend um so for um the community benefit program and the 889 it's it's specific to oregon so if you are have a health system and you have two hospitals in washington um those the community benefits spend for those hospitals and clinics does not count um so and or if you're in alaska or california or whatever so it's just your oregon facilities and dollars that were spent in oregon um and same goes for um senate bills 889 the 3.4 percent um accountability lies with just um uh people when we're talking about those that are attributed people in oregon so um hopefully that answers your question let's see is there i'll stop sharing my screen um is there are there any questions for me and andy together or or broadly um or anything else we can help you with this morning looks like there was some questions in there um for a multi-state health plans did we grab that chat yep i just answered that one [Music] well great session you guys thank you very much very informative lots of information to take in um definitely appreciate you guys joining us today um so thank you very much for that presentation um for everybody else um you know that thank you for attending our first session um please make sure you click on the survey link in the chat box to take our surveys um it's always great to have your feedback a special thank you again to key bank for sponsoring this event i appreciate your ongoing support thank you