 Okay, it's one o'clock. My name is Kevin Mullen, Chair of the Green Mountain Care Board, and I'm going to call this meeting to order. The first item on the agenda is the Executive Director's Report, Susan Barrett. Yes, thank you, Mr. Chair. A few items to announce. First, that we have extended the public comment period for those sustainability plans until this Friday, July 31st. We were initially going to take those back up with a potential vote on the 29th, but our schedule got quite busy, so we are now going to take that up again on August 3rd, which is next Wednesday. No, sorry, August 5th. Thank you. And we will have that on the agenda and schedule a potential vote on those sustainability plans as well. The second item I wanted to announce is that on this Friday, July 31st, hospital budget submissions are due. And then lastly, the decisions for the QHP Qualified Health Plan rate filings and rate review will be issued on August 14th, and all of that information can be found on our website in various areas. And if you have any questions, please reach out to Abigail or myself. And now, and actually I could turn it back to you, Chair Mullen, but I know General Counsel Barber had an announcement as well. Go ahead, Mike. Thanks, Kevin. So the board has to announce its rate decisions in a public meeting, so I just wanted to announce that on July 17th, 2020, the board issued a decision in order with respect to the third quarter, 2020 large group rate filings of Blue Cross and Blue Shield of Vermont in the Vermont Health Plan. The board ordered the carriers to reduce the proposed manual rate increase from 1.9% to approximately 0.7%. Groups, large groups will experience premium changes that vary from this approved manual rate because each group's premium change will account for its recent claims experience and other factors, but the board estimated that the average group may experience a premium increase of approximately 4.7%. That's all. Thanks. Thank you, Mike. Next, I'm going to go to the minutes of Wednesday, July 15th. Is there a motion? So moved. Second. It's been moved and seconded to approve the minutes of Wednesday, July 15th without any additions, deletions or corrections. Is there any further discussion? Hearing none, all those in favor signify by saying aye. Aye. Any opposed? So at this time, I'm going to call out just the numbers that I don't have a name for on the list, and this is for the purpose of keeping the public record of attendees. So when I call the last four digits of your phone number, if you could just say who you are. Now are you having technical difficulty? It won't just scroll. Maybe Abigail can see it and she could call it out. Yeah, I can do this. 4-0-2-8. This is Kylie Kuiper from the Office of Healthcare Advocate. Thank you. 7-7-9-6. That's me. That's Sarah Cook-Berry. Thank you. 8-7-0-3. Mike Del Treco. Mike 6-3-7-6. Mark Wasserman. I think more 2-7-9-6. Carol Stone. Thank you. 3-2-1-2. Hi, it's Kathy Mahoney. Kathy, 5-8-1-7. Hi, Joseph Hopkins from the Vermont Medical Society. And I have the names of everyone else, so thank you very much. Super. So with that, I'm going to turn the meeting over to the ACL team and Elena, are you taking the lead? Oops, you're on mute. You can't hear me. Okay, there we go. So I'm going to try to share my screen. Let me know when you can see that. We can. Okay. Okay. Is it large enough? Yes. Okay. Great. So today we're going to discuss One Care's 2020 revised budget that was recently presented by One Care to the Board. The staff, you know, normally this presentation would happen in the spring, but for a series of reasons, you know, in COVID, among others, this was postponed and we are here today. So we'll talk about that, but I'll be presenting today with Marissa Melamed, Michelle DeGree and Sarah Tewkesbury. So these are all members of our ACL team. And they do, you know, different policy work across the Green Mountain Care Board. So, you know, we'll give you some background about, you know, how we got here today and then some additional context that might be helpful for considering the further discussion and then, you know, go in to more detail from what we have of the ACO 2020 budget revised as of June 16th. So budget, you know, can always change, but this was the latest version that has been submitted. We'll discuss the next steps and open it up for questions and public comment. And then, you know, some appendices that we've included were included in the fall presentation might be helpful for additional detail. Okay. So, you know, just some background. This is grounded in our statute, our authority for oversight of accountable care organization. So there's two processes, certification and budget. We're really today only talking about the budget. And, you know, as I mentioned before, this kind of review where we look at final attribution, the budget and kind of where the contracts, payer contracts landed really happens in March, the around the March time period. But because of COVID and, you know, a lot of uncertainty, some of those contracts had to be renegotiated and, you know, the budget was a moving target. So that's why we're, you know, we're talking about it, you know, now as opposed to in March. And then, you know, just to recognize that there's ongoing monitoring that will continue to happen throughout the year. So normally, monitoring against the budget order would happen separately from kind of this revised budget look, but that we're kind of combining these elements today. So it might be a little bit different than what you're used to. And we did that in recognition of the work that the ACO has done today and the deliverables that they have made, and then to give the board additional context as we gear up because 2021 is actually just around the corner. As you know, we issued the guidance not too long ago. So, you know, just to kind of revisit the timeline, you know, we issued the budget guidance for 2020 and 20, you know, July of 2019. So it's over a year ago. You know, a lot has changed since then. They, one care submitted their proposed budget for 2020 October 1st. Yes. I hate to, I hate to cut in, but there are some people that are doing this just by phone and don't have access to the screen. So if they're following maybe you could just mention like right now we're on slide six. Yes. Thank you, Kevin, for the reminder. I have trouble remembering that. So yes, slide six. And, okay, so they submitted their budget in October. And then we issued the budget order in early 2020 after the vote, board vote, I think at the end of the year. And then, you know, March 13th was when we declared the state of emergency around COVID. Shortly thereafter, one care requested operational relief. So there was a number of deadlines associated with the budget order that were postponed. And, you know, we worked part of that was there was a lot of uncertainty around contracting. So, you know, we worked with you, Kevin, to make sure that we had a process that would incorporate the most amount of information without, you know, indefinitely delaying. So that's why we're here in July. And oops, just to, you know, there is one amendment to the budget order as a result of that earlier request that was made in in May that that pretty much just, you know, allowed one care to provide funds back to the provider network as efficiently as possible. In the case of the VBIF funding, and then postpone those deadlines. So the budget order should be looked at in conjunction with the amendment. So some additional context, you know, so as I mentioned, staff analyze one care is June 16th revised budget. We're on slide seven now in the context of the budget order. So we've not identified any necessary budget order amendments at this time. But we do expect additional deliverables from one care in the near future and we'll bring any relevant insights for the board. That doesn't mean that we expect any additional amendments to the budget order, but we don't know what those materials look like yet. So we won't weigh in on that until we know. And then, you know, we I think we need to recognize that COVID is not not yet behind us. And so there are a lot of uncertainties for the remainder of the year. So I think 2020 as we've all recognized is quite an anomaly. So it's it's difficult and it's a moving target. And we just have to continue to work together to make this work. So the revised budget. So as I mentioned, we have our ACO team that will help work through all of these sections. We wanted to really, you know, to the extent possible reproduce the analysis that we put forth in the fall, we will try to skip through a lot of the context that you might already have and really focus on those changes. So, you know, it is still a lengthy presentation, but we'll try to move as quickly as possible. So we'll discuss payer programs, the provider network, the implications for our all payer model requirements around scale, the quality components of our all payer model on down, and then the ACO's financials, their risk model, the model of care and population health, and then evaluation. And now I will turn it over to SJ. And we're on slide 11. So SJ, let me know when you'd like me to advance the slides. Okay, great. Thanks, Alina. For the record, this is Sarah, who's already helped policy analysts with the Green Line Care Board. Karen Mullen, can you hear me all right? We can, yes. Thank you. Great, that's such good news. So I'm on slide 11 right now. I'm looking at the payer programs overview. And on this slide, we have an overview of one care's payer programs for FY 2020, which is currently comprised of care programs. We have Medicare, Medicaid, and other agencies initiatives across Lujo, Vermont, and the state. Unfortunately, Sarah, we're starting to lose you. Can you still hear me, Kevin? We can now again, but it was jumbled there for a while. It could also just be my personal model. I'm trying to speak up a little bit. On this slide, there's an opportunity for further commercial alignment. And what the Green Line Care Board means by alignment is explained in Appendix 3 of this presentation, which can be found on slide 22. All payer model-required programs designed across the payer reasonably allowed for the generation initiative in the areas of attribution methodology, quality measure, and services, including the term, I think we lost you again, Sarah. Elena, we may have to move forward in the slide to come back to Sarah. This is Michelle. I'll just give Sarah a bit of a reprieve. So Sarah actually lost power today and is taking this by phone so that she can sort of get service. So clearly that's not working super well, but maybe Elena and Marissa and I, we can maybe handle some of this. Hi, Sarah. I'm back. Can you hear me? Okay. We can now. I'm sorry about that. Let's try this one more time. And then if I cut out again, I'll hand it over to Elena. Are you still able to hear me? Yes. Okay, great. So just to confirm, I'm on slide 11 and I was just doing an overview of the payer programs. The one thing that I really want to highlight before I move on to the next slide is that out of these payer programs, the board could do a little bit of work around the timeline or goals for commercial partners to participate in moving to value based payment systems and away from fee for service. Because right now what we see is that the commercial programs are not as aligned with the all payer model goals as the Medicare and Medicaid are. Moving on to slide 12. This slide is about the budget order condition number two, which was about one care. They were directed to submit a scale target initiatives report. We did receive this report on March 31st for the contract executed at that time. But to date, the Green Mountain Care Board is still waiting for one care to submit materials associated with the non-risk Blue Cross Blue Shield Vermont program. So that is one outstanding deliverable item. Moving on to slide 13, we're looking at the budget order conditions number three and four. Number three is about a one page document summarizing the benefits of self-funded payer programs that the self-funded payer programs received by participating in one chair. We did receive this on March 31st and the criteria was met. The criteria was also met for budget order number four, which was that one care must submit a Medicaid geographic attribution implementation manual. This work is evolving and what we hope to see in the future is one care sharing lessons learned and challenges that they faced along the way with the geographic attribution implementation manual. So you'll be seeing that in the FY 2021 ACO budget process, but to date the criteria was met for FY 2020. Moving forward to slide 14, I'm looking at budget order condition number five, which pertains to the payer contract and benchmark trend rate. The Green Mountain Care Board received original contracts from one care on December 27th, 2019 and then renegotiated contracts on May 5th of 2020. Commercial contracts under the Green Mountain Care Board are under the Green Mountain Care Board staff review, but one care has not provided actuarial certification for the commercial program. You'll see on the slide and I'm just going to read this so that I get the language correct, but the one care Vermont stated the following in their July 20th materials that they submitted to us. They stated that actuarial or excuse me, actuarial for the commercial insurers who'd follow up to the targets would be a more appropriate recipient of this request. However, the budget order and the way that this condition has been implemented to date is for one care to provide the actual certification to directly to the Green Mountain Care Board. The ACO can request relief from this condition formally if it is unable to provide the actuarial certification directly to the Green Mountain Care Board. However, to date the Green Mountain Care Board has not received any formal requests from one care to delay or refuse this budget order condition. Moving on to slide 15, this slide is just a recap of the budget order conditions that pertain to payer programs. So we recommend the GMCB staff recommends no changes to the budget order needed for number two, three, and four. What I was just speaking about for budget order five is not necessarily a change, but it is. We just wanted to highlight that we have not received all of the deliverables that we've asked for today. And then the other opportunities based on staff analysis, as I mentioned in the beginning, but partially was cut off when I lost you guys for a moment there, was about, you know, we can talk about other opportunities for a path for future commercial program alignment, which the staff plans to address in the FY 2021 budget process. So next we have the provider network. This slide, I'm looking at slide 17. This slide summarizes one care provider network changes as were submitted to the Green Mountain Care Board on October 1st of 2019. There have been no changes to date. The final provider network for FY 2020 continues to be outstanding from one care. I mean, we just haven't received that yet. So what you'll see on slide 17, 18, 19, 20, 21 are all, those are all slides that we can just sort of skim through. Those have not changed since the Green Mountain Care Board staff presented to the board in December of 2019. Because like I said, we're still waiting for the final provider network to come through. So that being said, we have dipped a little bit ahead and are now on slide 22, which pertains to the only budget order condition related to the provider network, which is budget order condition number one. And one care was required to submit a network development strategy for 2021. And it included a list of criteria. The ACO did submit this to us on April 15th, and the Green Mountain Care Board staff determined the criteria had been met, but only after a series of follow-up questions had been addressed and answered. So staff reviewed this when it was submitted on April 15th. We formalized a list of follow-up questions, sent it to one care, received their answers, and then determined that the criteria had been met for this particular condition. So now slide 23, just to recap, budget order condition number one was met, and no changes to the budget order are needed at this time. And now I will hand it over to Michelle Dugree. Okay. Can everybody hear me? Yeah? Thumbs up? Yes. Yes. Okay. Great. So talking just sort of briefly about scale and its relation to the ACO process. So Elena, if you want to go forward to slide 25. So just a reminder, between the payers and the providers, that's kind of how we get to scale. So the percent of remonters attributed to a scale target initiative. Again, those have to be ACO payer programs that meet certain requirements set forth in the agreement. Most notably, they have to be risk-bearing. And so the scale targets outlined in the agreement are to ensure a critical mass of Vermont's population is engaged in reform efforts. So you can see sort of where we're supposed to be per the scale targets set forth in the agreement. I think one thing that just quickly want to talk about as we think more towards 2021, you know, thinking back to the recommendations or the conversation we just heard from Sarah Tewkesbury regarding payer program and provider network. These are sort of our levers by which we can affect scale under the all-payer model. So just sort of keeping that in mind while we go through the next couple of slides. And I talked to you about spoiler alert, how we didn't meet scale. So Elena, if you want to go forward. Thank you. So this is a slide that you all are pretty familiar with. Thank you to Sarah Lindberg for updating this for 2020. Just a reminder of all of the puzzle pieces and how they sort of stack up together and where things are the same and where they're different. And again, the total cost of care denominator drop because of the GO-BAY decision has remained quite steady as you can see from that initial decline. So Elena, you want to go forward one? All right. So as Sarah and Elena have both talked about now, we've got some payer programs in effect for 2020. We have here on this slide showing projected attribution as of October 1st, the revised attribution that we received in June, and then just sort of showing that variance there. Some of this production is going to be natural. As we've said before, for Medicare, it's typically due to death. Some of the other ones are likely due to contractual changes between October 1st and June 16th. And again, the scale target qualifying total that we're looking at for the June 16th is that 223 number. The Blue Cross Blue Shield primary program that Sarah just talked about is not scale target qualifying. So it will, those 44,000 lives do not count towards scale. Elena, if you want to move forward one slide. Thank you. So what I tried to do here is make something easy that's not inherently easy to understand. So while we've made significant increases in scale since 2018, they're not quite at the trajectory set forth in the agreement, as we know. Performance year two results reflect significant growth in attributed lives since performance year zero, which began in 2017 and was just the Medicaid program. Most notably, the number of Medicaid beneficiaries attributed under that the MNG program, which launched in 2017, increased by 45% in performance year one and nearly doubled again in performance year two. And we've got 2020 attribution in the Medicaid program to exceed 100,000 lives. So just kind of wanted to point out sort of the wins here before I talk about the hard stuff. So the, what I've done here is the initial October 1st estimates that we just had from the previous slide are pulled over into that column under 2020 that again says initial. And then we've got the revised attribution numbers and the projected scale target performance for 2020. So the red with the down arrow is showing a change. So initial scale using those October 1st numbers would have yielded a 47% all payer and a 47% Medicare scale. However, the revised submission with the decrease in lives gives us a 44% Medicare scale, which decreases by 3%, which you see noted there. And revised all payer scale lands us at 42%, which ends up being a 5% decrease over that initial attribution estimate. Again, the one thing to point out here is that these performance numbers utilized 2019 APM population. And so once that's updated in 2020, that grayed out column there, which Sarah Lindberg updates for me annually and is so helpful, but relies on things like census data and other data that is not yet available. So these numbers are likely to change once we have that revised population estimate as well. I know that's a lot. I tried to make it somewhat easily understandable. But I just wanted to show that the decrease in scale has, you know, the decrease in attributed lives does have a pretty significant impact on scale. So Elena, if you want to move forward one. So we'll be on slide 29. This is just a reminder. I know most folks know this now. In the spring of 2019, the Mountain Care Board and the director of health care reform at the agency of human services conducted a scale target survey, findings fell into the responsibility of three parties. We had the state and federal government and the ACO. So here we're specifically talking about the scale strategies identified for one care. And they're listed here. I just kind of want to find out results from the survey kind of showed that in order to increase participation in the model and achieve scale targets, hospitals and FQHC must believe that all payer models payment structure is transparent, predictable and sustainable. And that payments from the ACO and participating payers must offset additional administrative and reporting requirements and incentivize delivery system reform with a greater emphasis on prevention and health improvement. So again, these five strategies were sort of under the purview of the ACO. So we're looking at designing an option for primary care to join without a hospital partner, offering multiple risk models, improving clarity of contracts with FQHCs, offering or facilitating network-based telehealth opportunities to smaller providers, and continuing to improve care navigator to allow for use for all patients, not just those who are ACO attributed. So really trying to reduce that burden. Elena, if you can move forward one. By clarity, talking about the budget order conditions here. So, you know, as I just talked about, we've now failed to meet scale targets in performance year one and performance year two, and are projecting another miss in 2020. We suggest we need to revisit the ACO scale strategy survey and better understand next steps and timing as it relates to the survey that they conducted. So that's all I'm going to say there, that's our recommendation. Elena, if you want to move forward one. Thank you. Slide 31, budget order condition. This was number seven. There were no changes needed. But again, we could ask for more information about the timeline and next steps for scale strategies. And there are, there have been other opportunities that potentially noted for scale. And Elena is going to talk to you about those a little later on in the presentation. All right. One more session. Now we're going to talk about quality. So, Elena, if you want to move to 33, yeah. So this is slide 33. As we know, the all-pair model agreement establishes a quality framework, and it requires the state to maintain, if not improve performance across a variety of care and population health measures. The ACO and its participating providers have their own sets of quality standards through their payer contracts. And although they're not always identical, they align to the quality framework in ways that make sense for each payer. So we're talking about different patient populations by these payers. And so a little bit of fluidity there is, is necessary. And just wanted to point out a reminder here that there's quality specific rule five requirements as well as agreement requirements. Elena, if you want to move on to the next slide. Slide 34 is half of the crosswalk of quality measures for the 2020 contracts and the information that we have to date. I want to thank our legal staff for working through this with me and making sure that we were able to present this information today. So thank you to Council Barber and Lynn Combe. So here, you know, this is something that you've now seen three years in a row. So we've got all of the all-pair model measures in the first column, and then we look at the 2020 Medicaid measures, the 2020 Medicare measures, Blue Cross Next Gen and the UVMMC contract. So that's the Blue Cross QHP, not the Blue Cross, not the other non-scale target qualifying Blue Cross program, and then the MVP measures as well. So you can see we've improved some of our alignment, especially within the commercial pair programs. We've got several measures that align across pairs. There's a few that are treated same measures that just treated a little differently. So you can see in the initiation and engagement of alcohol and other drug dependence treatment, they're separate in the all-pair model. We report them separately. Medicaid and Medicare also report them separately, but Blue Cross and MVP report those as a composite measure. So just, you know, same, just a little different. Elena, if you want to go to the next slide. So this is slide 35. This is the other half. And again, same process here. We're looking at a lot of alignment across pairs, which is very promising. And so this is what we've got looking forward to 2020. Elena, if you want to go forward one. Thank you. So slide 36. This is just sort of revisiting everything that's come out so far. So you will recall that in November, Elena and I played the part of Medicare and in presenting the ACO pair program results with the other pairs. And this is something that we plan to continue annually. So sometime around November 20th, we will again sort of review those results. There's the APM 2018 results, quality results that report has been released. There are the proposed technical changes. So again, there were some potential changes to the quality framework in the amendment. As you know, that has sort of stalled due to COVID, but the report itself was released based on the mutual understanding in that change. And then there's been quite a few letters, which Sarah mentioned earlier, just related to COVID and its impact on the ACO. And number five is the quality of care report that I was just mentioning. So Elena, if you want to go forward one. All right. So this was budget order condition 16. And staff has determined that compliance with this condition will be assessed based on deliverables associated with it, which are currently under staff review. So I don't really have tons to update on at this point, but it's something that we'll continue to work through and present updates to all of. Elena, if you want to go forward one more. All right. So budget order item 13, no changes needed. Other considerations, are there recommendations to be had related to COVID-19? Moving into 2021, we will have a better understanding of the impact of COVID in 2020, just given run out and claims sort of processing. So should we add measures to look at care patterns, telehealth, something that we're considering for 2021? It's something also that our Green Mountain Care Board staff are working through with some of our analytic partners in potential impacts to our total cost of care reporting as required through the all pair model agreement. And so, you know, trying to sort of tie that thread through some of the other processes and just ensuring that we really are capturing a change in care patterns, if that's what we ultimately see. And that is it for me. I will pass it on to Elena. Great. Thank you, Michelle and Sarah. So I'll talk now about the financials that were submitted. So as you'll see, there was an almost 12% decline in top line revenue driven mostly by, you know, that declining attribution. We did see an increase in payer program support, but a decrease in the state support, so it's the DSR funding, as well as a decrease in participation fees, which was helpful as providers, you know, are looking for more funds to address kind of COVID concerns. And then there's a decrease of about 20% in other grants and deferred revenue. So we're looking for some more details there. In terms of expenditures, it was help, you know, we saw, you know, this provider reimbursement is in parallel to the revenues that you see above. The One Care Administrative Expenses, they have talked about, we saw a decline, you know, 22.6%. You know, they, One Care acknowledged some driving sources of that decline, but we just only recently received their more detailed financials and haven't had a time to incorporate that into this analysis, but we will be kind of going back and looking at that as well. And then as they also talked about, you know, we've seen a decline in population health investments, which One Care went into great detail to explain during their last presentation. So normally, we'd like to give you an update on the breakout of fee for service or fixed perspective payments by payer to kind of get an idea of where we landed. This is not something we had time to update given the materials that we've received. So, you know, we hope to bring this back to you and date in the future. In terms of provider dues, I mean, what you'll see is that they've reduced provider dues by that 6.2 million, which is approximately a reduction of 26%. And then in the column up to the right, you can see the proportion of total that each hospital is funding. This slide is a carry forward with minor tweaks from the 2020, the earlier cycle. One thing that we would like, so this is updated, but you know, I think we need to note that Springfield had some reporting discrepancy. So it's reported as zero. We know it's greater than zero, but we will update this when we get additional information. In terms of the administrative expense ratio, so looking at the ACO operational expenses, relative to ACO total revenue, we've included here a look over time. This did decrease, like I said, by 23% the admin expense, but revenue also saw a decrease of negative 12. So that gives us a new ratio of 1.19%. This is within the parameters of their budget order, which requires one care not to exceed 1.35%. Or if revenues decrease, we actually allow them to go up to 1.6%, but I think in the spirit of COVID, you know, it is appropriate that they've made efforts to decrease their administrative expenses. So at this time, we don't see any need to make any changes to the budget order condition around administrative expense. So as I mentioned before, we received the financial statements, you know, very late on, you know, just two days ago. So we have not had time to incorporate that into this analysis. It's under staff review, but if we find, you know, that that analysis drives any changes in this analysis that we're presenting today, we'll bring that before the board. So other relevant conditions, we do have a budget order condition around the use of one care's reserve. I underlined engaging in sustainability planning here for, you know, we can talk about whether this still makes sense. But, you know, one care is not indicated so far that they intend to use this reserve. But as I mentioned, you know, I don't think this needs to be changed, but we could talk about whether or not we remove sustainability planning to broaden the pool of applicants, especially in light of COVID and thinking about, you know, all risk-bearing entities, not just those that are a subset that were included in sustainability planning. So I know that's kind of a moving conversation as well. In terms of the ACO risk model, you know, I kept some of these context slides that I was helpful to remind everyone the difference between insurance risk and performance risk, you know, the payers pass down, you know, really deal with the insurance risk and the ACO is trying to do work to help hospitals manage their performance risk. And, you know, in their model, they accept risk from payers and pass it through to hospitals. And, you know, this is how it's currently structured. And risk-bearing entities could be more than hospitals, but today, you know, they've primarily focused on the hospital-centric model. So, you know, while I mentioned, you know, while risk is negotiated between payers, it's really up to the ACO to decide whether and how they distribute the risk across risk-bearing entities. And of course, the risk-bearing entities have to accept that risk. And there has been no changes to one CARES risk model to date, and they pass this performance risk uniformly across hospitals who have been the primary risk-bearing entities. And then founders may agree to backstop a hospital's performance risk on a case-by-case basis, meaning that they would carry some or all of the risk on their books. And, you know, we know that risk has been cited by some providers as a barrier to scale, so we thought it important to discuss this. You know, as I mentioned before, we are still waiting on some outstanding materials from one CARE. And we heard, oops, we heard verbally that there might be some changes to the way shared savings and losses are distributed that might, you know, provide some additional context to this conversation. So this is the hospital maximum risk limits. You know, I would have liked to update the slide. This is a pullover from October 1st. But given the data that we have from the hospital budget submissions, we did not want to over-inflate the day's cash on hand, given there's still some accounting intricacies to understand and clarify before we can get a more meaningful measure. So, you know, this is a snapshot of October 1, but we'll continue to monitor kind of the impact on hospital situations as we get more information. So we have a budget order item about the maximum risk that one CARE may assume in 2020, and it amounts to certain thresholds. But we still, the one-piece input here is really the commercial contracts and actuarial certification because this budget order is tied to some of those previous budget order items that are conditions that we discussed earlier. And then we just wanted to note that due to dramatic declines in Medicare expenditures associated with COVID and foregone utilization, we expect CMS will request a recalculation of the Medicare benchmark by invoking the Exogenous Factors Clause in the agreement. And the process and parameters for this recalculation are currently being developed. We have been looking at some guidance that they've issued, but it hasn't given us, you know, great clarity, especially with this moving target about what that will look like on the ground. You know, one's established staff will return to the board with details and estimates on the budgetary impact. The associated risk will likely decrease, so we don't see this being an issue for the budget order, but it's something certainly to keep track of. So we have another budget order item related to risk in which one CARE must implement the delegated risk model that it described in its budget, you know, accept that it must also submit copies to the board of the contracts that bind each of the risk-bearing hospitals to one CARE risk-bearing policy. For those hospitals that are not covered 100% of their risk need, you know, the letters of credit. And then we have to inform, you know, they should inform the board whether it has secured the aggregate total cost of CARE protection for Medicare and notify the board within 15 days of any changes to the risk model. So, you know, as I mentioned before, you know, this last piece we are, we understand that there may be some additional information coming, but there has not been a formal notification at this time. We have received 11 C, but still are waiting for A and B for 2020 related to this budget order item. So we don't see any changes. We're just waiting on more materials. And I think another point to keep in mind, and it may be more appropriate for FY21, but, you know, one CARE could certainly report on whether and how the risk model supports all-payer model scale since it has been seen by some as a barrier to participation and to the extent that it is up to the ACO to, you know, design and implement a risk model. It would be helpful, I think, for the board to understand how that supports scale in their minds. So I don't think we've really had a robust conversation on that today, but it might be helpful as we continue to try to achieve scale. Okay. And now I will pass it over to Marissa. Thanks, Elena. Thanks to Sarah and Michelle as well, and good afternoon, everyone. Today I'm going to talk about the model of CARE and the Population Health Investment Section. You can advance to slide 60. And I apologize, I might have a delay on my end, but I can see it now. The initial budget presentation used these graphics to ground us in where the ACO fits into Vermont's Population Health Plan. It's important to remember when we're looking at their model of CARE and their investments in Population Health that the ACO operates within a larger statewide framework for Population Health. I think we can't remind ourselves too often what an ACO is and that they're a group of healthcare providers that voluntarily come together to agree to be accountable for the care and cost of a defined population of patients. So we want to make sure we remember it in that context when we review these programs. Next slide, 61. So in June, one CARE submitted and then presented on their revised budget. This included a drill down on changes to their Population Health investments. One CARE leadership and their board made revised budget decisions in light of the circumstances of the COVID-19 pandemic and they developed a guiding set of principles to inform those decisions. As a reminder, those five guiding principles were to sustain existing one CARE programs, to sustain committed funding to network participants, to target initiatives with significant operational resource demands, prioritize initiatives with potential short-term financial and clinical benefits, and target initiatives that are funded by hospital dues. So staff viewed these changes in light of the budget order conditions and the amendments to the original order in April and to the criteria defined by one CARE in their June deliverables. You can advance to slide 62, which shows the same information but illustrated in a different way. Again, this is updated from our original budget presentation. You can see the steepest reductions in programs are those that are tied to payer contracts and community-specific projects. The blueprint for health funding remains stable and the budget revisions that you see here provided necessary dues relief to hospitals during the pandemic public health crisis and allowed one CARE to continue their core programs and sustain stable funding to network participants during the a period of steep revenue drop and uncertainty. Slide 63. So since 2018 the board has looked at the population health management ratio and the dollar figures and ratio calculations over time are provided here. We have historically illustrated two ratios and that is the public health management total minus the blueprint funding and that's because that's a fixed amount that one CARE doesn't control. So the PHM amount minus the blueprint over revenues, total revenues you can see on the second to bottom line there and then the population health management total over the total revenues. And as you can see the ratio has seen moderate decline as the total revenues flowing through one CARE has increased and we have we did discuss this in our initial budget review. You can go to the next slide 64. A little bit about that discussion. Go ahead to we're looking at 64. Historically the board has set a population health management ratio to ensure that one CARE maintains a certain level of population health investments relative to scale in their overall budget. However we recognize that not all public health spending is scalable by attribution meaning not all public health investment can increase at the same rate as revenue growth to increase participation. So during the budget order we started a discussion on how to determine the appropriate measure for population health management spending but the budget order did not include a condition on this ratio. Staff postponed the PHM recommendation to collect more information and rethink the methodology for calculating the PHM ratio. So the difficulties in calculating this ratio would be further magnified under the current COVID situation. COVID has significantly altered the context for population health investment. Providers are facing financial challenges that inhibit their ability to pay dues to the ACO and those dues have historically funded population health investments. In addition the CRF or coronavirus relief funding was made available to providers on the condition that population health investments continue to help maybe help to stabilize this funding in the crisis. This is Act 136 of 2020 and staff will update the board when grant details become more available and you can advance to 65. Well so in conclusion on the on the previous one we're in a you know the situation is still in flux as Elena's is discussed and so while you know the PHM ratio was a discussion initially it continued to be a discussion and it will you know be part of the 2020 discussion and the 2021 discussion as well and there's no additional recommendations on that this time but we are you know keeping it in mind and it's you know top of our minds as we review this budget. So here on slide 65 the budget order included there's four conditions that are related to population health specifically so I'm going to review those briefly. Condition 13 again this has been addressed in their revised submission and additional materials that were submitted on June 19th and July 20th so the criteria has been met. We have follow-up questions that we are continuing to look into and we will update the board as we have more information on this one. Slide 66 conditions 14 and 17. One care must fund the SASH and blueprint for health payments in the amount of 8.4 million. They submitted documentation on this June 19th. One care indicated this amount will be met and staff will confirm at year end that these funds were invested by one care according to their intended use for condition 17. This was amended in the budget order so the new date is now September 30th to next slide please. Slide 67 budget condition 18. This is regarding the work plan to evaluate the effectiveness of population health investments. This was submitted on June 29th meeting the criteria but we are also continuing to pursue a follow-up questions on this item and can update the board as we have more information. Next slide 68 is a summary of the budget order conditions pertaining to population health. So again 13 and 18 are to be determined under staff review and 14 and 17 there are no changes recommendation recommended at this time. Other considerations as I discussed historically the board has made a determination on the population health investments at a certain level. This is in flux the context has changed. We're continuing to monitor ask questions about it as we learn more and in addition whether and how to consider the coronavirus risk relief funding that's available. That concludes my remarks on population health section. Next on evaluation slide 70. Evaluation of the accountable care organization and the all-payer model is an important and ongoing discussion. It's addressed in several ways across green mountain care board regulatory and reporting processes so not just through the ACO oversight. On the one side there's the all-payer model reporting that Michelle has discussed quite a bit including total cost of care quality participation scale and the federal evaluation that comes in the middle and at the end of the model. On the ACO side we have our budget review which is programs and finances of the ACO as well as certification which looks at policies and procedures. These things are interrelated but this is the framework that we you know in an overview of the framework we use to evaluate the model and the ACO. Our focus today is within the ACO circle so recognizing that evaluation you know of the ACO and the model are interrelated. So slide 71 again same but you can go back to 71. Same information I just I just reviewed how are we monitoring progress in these areas. There's links to reports starting broadly focusing on number two we monitor scale provider and payer participation in attribution through the ACO budget process. We monitor payer program results on finance financial and quality results and then drilling down to what we're talking about today which is the budget order and there's two relevant conditions to evaluate in the budget order and that I will discuss as we go forward. So let's see you can go to slide 72. So budget order condition number 20 reads over the duration of the all-pair model agreement one cares administrative expenses must be less than the health care savings including an estimate of cost avoidance and the value of improved health projected to be generated through the model. So we've illustrated it in the equation below for those who like to see it that way the sum of the results over the five-year duration of the model we have the value created over the administrative expenses and those should be greater than one. So this obviously is very complicated we need to define the inputs into this equation and there are many value variables that go into this. We need to do an assessment of the value the value generated as a result of population health investments and improved care integration. This includes economies of scale through centralizing shared data infrastructure analytics and care coordination and again you can you can drill down to the measures here so are there clinical measures such as ED avoidance or lower acuity of care that show value you know the question is how do we calculate a value of improved health or care not needed and how do we calculate the value of the population health programs that I discussed in the previous section. So overall if you think back to the slide I showed at the beginning with the two circles we're looking into what is the right framework for evaluating the return on investment in the ACO to Vermont's all payer model goals I don't have a slide for this it's it's just back to the first slide. We know that return on investment is a challenging measure for population health programs because the costs and the benefits are diffuse they accumulate over a long period of time. We have to answer not only basic questions about what are the inputs for revenue and expenses but also over what time can results be reasonably expected and to which stakeholders in which sectors do the savings accrue. There are many questions here that still need to be answered but the budget order condition is included here because it is important so we are continuing to look at this we expect to work with the ACO to document and propose a measurement we want to be active partners in figuring this out together we'll likely need to engage a third party to help finalize and design the framework and the timing will require data over the full duration of agreement as is illustrated here. In addition just another note of evaluation our team is also exploring other frameworks for example using the state's results based accountability framework for evaluating the ACO and the oversight processes and as we you know are able to work through that more we'll update the board when it is more fully developed and that concludes my remarks on the evaluation section. There are a couple budget order conditions that are included that we haven't talked about yet so I'll just kind of breeze through those to round it out so we you know initially included an April 15th date for one care to present to the board on as we mentioned their final attribution payer contracts revised budget etc so due to COVID-19 and contracting delays you know one care's presentation occurred on June 24th so they've met that requirement given the amendment that was put forth and then and all that language. So condition number nine was for one care to provide the supporting documentation to that presentation so some of these deliverables were submitted on June 19th but there was missing information so additional materials were submitted on the 27th and we are reviewing that and we'll have kind of a list of remaining items if there are any after we've had a chance to dig into those materials. I do believe they're posted to the web if anyone would like to look at them. Budget order condition 15 is about the quarterly reporting and one care has been submitting their quarterly reporting to date so this criteria is currently met. Related to budget condition 19 around the prototype for a dashboard one care is working on this to our understanding and this date was pushed out to September 30th so for the prototype and then you know to be implemented by December 31st but given that the prototype has been extended we might you know we don't we'll have to look at that and see if it may still make sense because I believe there will be some some partnering around you know what what this should look like. It's a pretty big piece of work and then audited financial statements will certainly come after the close of the fiscal year so those are still forthcoming. So some next steps you know as I mentioned there you know we still have to do our analysis but there are some outstanding deliverables that we expect to arrive from one care for 2020 and 2020 is not over you know staff will finalize their analysis or we will finalize our analysis and once we have received most of those materials and then you know have a public comment period if if anything is needed at this time we've not identified any budget order items that are necessary and then the potential board vote if necessary would be scheduled at that point and then you know there's the benchmark conversation that will happen as we gain more clarity and then as we mentioned before the 2021 budget cycle is just around the corner but now we are to questions and public comments. Okay board questions. I have one kind of just kind of looking at the timeline here thinking back to our our first board order on the 2020 budget was December 18th and then we amended it on April 6th understandably because by then COVID had arrived and a lot of Apple carts were overturned but so this period since April 6th probably you know one might be able to step back and say it's been a real stress test and I'm just wondering if as under the kind of next steps are there lessons to be learned here in terms of the relationship between us and ACO what is you know what what are must-haves that we have to have and things that we might want to emphasize as we look at the 2021 budget and things that are nice to have but may not be as high a priority I'm just you know this is an unexpected stress test and as in any stressful situation you learn a lot and I'm just wondering if we have kind of an organized way to assess what we might have learned and amend how we do stuff and how we might ask the ACO to do stuff so that things work well absolutely can I respond just quickly so I think that's a really good point I we spent a large part of the 21 guidance development looking to streamline the approach and sorry I have bases on different screens I'm not sure I look to streamline the approach so we work closely with the ACO and receive their feedback on on where that administrative burden has been historically so we both and worked with a variety of you know stakeholders internally and externally to make sure that we had the right we still had the right level of detail and the right questions so you know but with COVID has any of that changed I don't know so I think it would be helpful for the ACO if they've identified any additional points of concern in response to COVID to let us know that I've not heard anything to date and we have asked for them to provide that feedback if they have it specifically so we can consider it and make any necessary adjustments so thank you Tom. And then just one other little request and this I think this has to do with the information that just came in recently but I took a quick look at Appendix 4.2 on their financials this was the income statement and it stops at 2019 budget and then jumps to 2020 round two and I just would be helpful to have the columns in there that say you know here's you know 2019 actual which we must have maybe actuals by now for 2019 here's the original 2020 budget and here's round two budget so that you can kind of follow the bouncing ball a little bit more easily than jumping all the way from 2019 budget to 2020 round two. Great yes we will we'll look at that. Thank you. Questions from other board members. Yes Maureen I just had a comment on when we're talking about the risk for the hospitals and the chart I think was on page 55 that listed you know what the risk court how much risk each hospital could potentially be taking and I think it would be good to marry that up with what their FPP that they receive is and show it as a percentage of that as well because I think that highlights what one of the concerns is which is for some hospitals it's relatively high to you know close to 10 percent compared to the FPP that they receive because a lot of the care is coming outside of their area so I think that would just be a comment to you know a different way to look at the risk by hospital. Yeah and that's helpful Maureen because I think there's still some lack of clarity on the risk model I understand that in the shared savings and loss calculation they might actually be doing some kind of adjustment based on patient flows and so I you know that's something I heard anecdotally but I had not seen to date in any of our materials so I think that's you know an area where we need to get some clarity on how their risk model actually works and what the appropriate metrics and ratios are and we've been working as staff to try to figure out how to how to get those details but I agree that that is a that's a critical look and we will move forward with that consideration. Perfect thanks and you know very comprehensive presentation. Okay how about the board? Sure it's Jessica just a quick one in this regards the population health investments and the CRF funding being conditional on you know maintaining population health investments I'm just wondering if somebody Marisa probably could you just give a little more clarity on what you do know about the CRF funding application and some of the stipulations there and how it applies to hospitals versus you know how this might factor in to this assessment. I wish I could Jess I can't because I'm newly getting up to speed on it I don't know if Elena has more but I need to learn more on it. Yeah I think Marisa it's not just because you're getting your feet wet again after being out for a while with your new baby but you know I think we're still waiting to hear from AHS on the the details of those grant programs so we don't know exactly how to think about those CRF funding yet in particular on a hospital level or what those terms or conditions are so we'll be you know we'll keep you up to date if we learn anything from our partners. Okay thank you so much. Did you have any questions? Go ahead. Yeah I just I more had a couple of comments on the attribution slide that Michelle went over slide 28. I think a couple other things that I would just I found interesting about sort of the shifts. One is that there was significant growth in the self-funded population which is of course a challenging area to achieve scale in so I thought that was good news as well. It was not a surprise about the Medicare decline in attribution due to Springfield hospitals financial issues and their decision to withdraw from the Medicare program so that seemed expected and the other piece that maybe I just missed it but we normally would see a decline in attribution from the submitted budget over the course of the year due to attrition of population so there wasn't a ton of surprises for me in the in that slide but I did find that you could kind of put together different moving parts and see that reflected in those numbers. On slide 30 which I need to remember what that is so hold on just one second while I look on my computer. Oh this is in the scale survey and the scale survey strategy. I just think it's worth thinking about whether whether and when a scale strategy gets sort of resumed because I think in the middle of COVID the considerations around scale are really different than they were when we did the scale survey so I think we just need to do some COVID related thinking in relationship to that budget condition as we move into 2021. I don't quite frankly my view on a lot of this is we're so close to starting 2021 we should just be moving ahead in our thinking and I had that same comment around slide 37 and slide 38 and I think that is it thank you. Okay anything further from the board members? Hearing none I'm going to open it up to public comment. Kevin this is Ham can I make it can I ask a question? You certainly can Ham good to hear from you. Kevin is the is a question appropriate here about the overall situation a little bit more than just the details of the ACO budget. What I'm curious about is whether a huge issue is what happens with the sustainability program. Can we talk about that or would you rather not do that in this meeting? So next week's meeting is scheduled to have that conversation about the sustainability planning if that's what you're talking about. Are you talking about for every hospital Ham? Well I'm just talking about the in other words in the last in your last meeting you're you're you're meeting on the sustainability budget on July 15th. The you projected there might be a vote then you got a very strong pushback from the from Vaz on that and and and if this is an expression that works the board sounded a little bit like a deer in the headlight and and and no vote happened I'm curious whether you're going to get a vote on the sustainability thing because that is going to be that's going to be a huge issue between now and the end of the budget. So Vaz asked for an extension in their comments back to us Ham we haven't seen what those comments are yet and so there could be a vote next week there could be something meaningful in those comments that we should be paying attention to as well. So next whether or not there will be a vote next week or not. I assume that's the goal. I would just say I think I just withdraw the question Kevin I can why I can wait till next week I think you need to focus I mean I don't have I don't have any questions about the ACO budget my questions are the broader system on the and and I can hold that until next week. Yep and everybody should be focused on the broader system and making sure that it's sustainable for the long haul so I look forward to next week's meeting. Other questions or comments on the ACO budget? Question. Go ahead. This is Dale. She mentioned a couple of times as far as the quality measures or the data in general. This is just a I'm trying to figure this out myself. I know that some hospitals the doctors can only see so many patients a day. There's only so much delivery of care some kinds of care that can be delivered in a day. How is that affecting the one care in terms of so to get the money even though they serve less patients I'm not against that. I'm not making any comment about that. I'm just curious how that that cat of services delivered in order to deal with COVID-19 is going to affect one care's data going forward. Hope that made sense. It did. Elena do you want me to take a first stab? Okay. Hi Dale. This is Michelle Degree. So I think one of the things that will continue to monitor as this year moves forward and well into next year as well I'm sure is is sort of looking at our baseline of services delivered and moving forward how that trajectory may or may not change and how care patterns might change or be delivered differently. And so part of what we're doing both within the ACO population or I should say what we'd like to be doing so run out is an issue as we all know and with COVID the first part of this year was very difficult to start to get data in on. So we're just now starting to receive some of that quarterly data that we would normally have had a couple of months back. So really trying to think through what our baseline was and how to assess moving forward again both for the Vermont population as a whole through our total cost of care. So really a subset of the Vermont population but then also the impacts that would flow through to the ACO based on that. Does that help? Yes. And then I think Dale the other the other part of your question was about staffing too right do we have the appropriate number of staff to for to see patients and see quality. I don't think that's something we have you know specific data on but it is certainly something to be considered in this model is is not only utilization you know especially utilization patterns are changing under COVID but you know staffing looks different you know we don't there are a lot of uncertainties right now and as Michelle said you know we'll try to kind of tackle that but I'm not you know getting down to those specific drivers is is certainly a challenge with the data that we have. Okay thank you very much. Thank you Dale. Other questions or comments from the public? Hi this is Sue Erin off from the Vermont Developmental Disabilities Council and hi I I have tried to find the information on your website that was referenced today the information that I guess just came in two days ago but and also the staff questions to one care in the past staff questions and answers have been available to the public so it could be I'm missing it it's there and I'm missing it that happens with me and websites often so if that's the case that someone could shoot me a link that'd be great and if it's not there then I would really ask that you post it because some of us are trying to follow this out here and it's a mess. The other thing so that's just one question the other thing is my understanding is that the Medicaid and Medicare data for 2019 is available so I would just ask you why wait till November to start talking about that I don't think it's too soon so that's my input thanks. Hi Sue this is Sarah Tewkesbury I just wanted to let you know that the data that was submitted to the board from one care on the 27th and actually also the staff follow-up questions that you referred to and we also referred to those are all in a zip file that can be found on the 2020 ACO oversight webpage they're right below the quarterly monitoring report links and they're right at the top I think I labeled them as FY 2020 revised budget so that should be a zip file and everything that you referred to should be in there I can also send you a link when I have a little bit better service but I just wanted you to know that those are and the rest of the folks on this meeting those are available on our website currently. Great thanks. You're welcome. Elena do you want to address the 19 info? Yes so I think you know while they might technically be available it'll take time for us to look at those and receive them look at them analyze them and understand what they mean and I think you know having a conversation across pair is really powerful rather than doing these one-offs so we can understand you know themes and and distinctions between them so you know that we're certainly going to have that conversation and we will do it as quickly as we can given our limited staff and all the other work we have going on but recognize it's a very important input to future board conversations so you know thank you Sue for your comment and we are we're working as feverishly as we can on as much as we can to do what we can for Vermonters so thank you. Yeah so it just is a follow-up it's been out there for a while on the 52 points of light that Diva put out that it looks like you know prior to processing and repackaging that there was like a 17 million dollar loss in Medicaid in 2019 so it has nothing to do with COVID so my fear and I don't think it's an irrational one is that because COVID is obviously the center of attention understandably that one care space of performance both in quality and finance from 2019 is just going to be swept away I mean there hasn't been a positive year of quality in Medicaid and it just hasn't been addressed so I'll leave it there thank you. And this is Susan Barrett Abigail Conley has put the link to our website where those documents could be found on the chat function of the teams program if you have access to that but reach out to Abigail or to Zira anyone on the line who needs access to that material. Okay other public comments or questions hearing none I want to thank the team for the the very informative presentation and the board appreciates that is there any old business to come before the board hearing none is there any new business to come before the board I would just say that Ham kind of gave us a preview of coming attractions that next week's meeting will be focused on hospital sustainability planning and we look forward to that discussion. With that is there a motion to adjourn? Second. It's been moved and seconded to adjourn all those in favor signify by saying aye. Aye. Aye. Any opposed? Thank you everyone have a great rest of the day.