 Okay, it's one o'clock and I'll call the order. The Green Mountain Care Board's December 7th, 2022, uh, board hearing today. We have a staff analysis and preliminary recommendations relating to the fiscal year 2023, one care, Vermont budget and certification. We have minutes from our Monday hearing down in Rutland on December 5th. I'm going to put those off until next week because I have not yet myself read them. And with that, I'll turn it over to Miss Susan Barrett for the executive director's report. Thank you, Mr. Chair. I wanted to thank Rutland community. As you said, we were there on Monday. We had a very robust day in the community. And I want to thank all those that prepared and shared their experiences with us that day. I look forward to planning more visits for traveling board meetings to other communities in the near future. Additionally, the Green Mountain Care Board had our data governance council meeting yesterday at that meeting. Board member Jessica Holmes was appointed as the board member on the council. She is filling the vacancy left when board member Tom Pelham retired earlier this fall. As a reminder, and for folks who may not know that the DGC or the data governance council serves several functions and it's the data governance stewardship council for the board. And those data sets that the board is responsible for are the cures, which is our claims data and vids, which is our hospital discharge data set. At our meeting yesterday, we reviewed 2 requests for de identified data for 2 research projects. All of the information regarding those requests and information on the data governance council can be found on our website under our data and analytics section. There are several special public comment periods that are open as a reminder. The board is currently reviewing the 5 year comprehensive 2023 to 2027 from on health information, strategic plan and connectivity criteria for 2023. Please submit any of your public comments regarding this plan to be considered ahead of the staff presentation and potential vote on that for next week. In addition, we are accepting public comments on the FY 23 one care budget. You will hear more about that from our staff immediately after I finish. And then last, but certainly not least, we have an ongoing public comment period for anyone interested in sharing their, their comments regarding a next potential model between the state of Vermont and CMMI. Any of those comments we will share with the governor's office as they are leading the negotiations on a next potential all payer model with the federal government. With that, I will turn it back to you, Mr chair. Great. Thank you very much. And without further ado, I'll turn it over to our team who's been working weekends, late nights, early mornings, all sorts of time getting this ready for everybody. And I'll let you all introduce yourselves as you'd like. Please go ahead. Thank you. This is Sarah Kinsler, director of health systems policy at the board. I am just going to introduce our staff team as we prepare to present you with our analysis and preliminary recommendations on one cares FY 23 budget and certification. So as as in past years, the Green Mountain care board staff has pulled together an interdisciplinary team to perform this analysis and and present it to you today. This is really a review based on the statute and and and all of the requirements that requires really broad expertise. So we bring together our policy team to look at payment and care models and intersection with the all pair model. We bring in our finance team to look at the financial analysis and intersection with hospital regulation. We review results and evaluation and data systems with our data team and our legal team works with us on compliance with the statute and rule. So all that said, there will be quite a few of us presenting today. In addition to myself, we'll have Marissa Melamed, associate director of health systems policy, Jennifer DePolito, our health policy analyst on our policy team, Russ McCracken, staff attorney, Matt Sutter, health systems, finances, print principal analyst and Michelle degree health policy project director. I also want to give a quick shout out to all of the others on the GMCB team who have had a huge part in developing this analysis. Michelle Sawyer, Sarah Lindberg, Flora Pagan, Lindsay Kill, Julie Bowls, and others as well. And we may call on them to help us answer questions or dig deeper into areas of board interest as they come up during your discussion. So thank you for hearing that. And with that said, I will pass it on to Marissa. Good afternoon, Mr. Chair, members of the board and the public. My name is Marissa Melamed, associate director of health systems policy. Our agenda for today is we are going to give you an introduction and background and an overview of a public comment received to date. We're going to walk you through our FY23 staff analysis and preliminary recommendations or approach to this year's budget review. We'll talk you through the next steps in this process, then turn it over for board questions and discussion and public comment and the key areas of review. We're going to go through or in that call out box. So briefly, the ACO oversight statute rule. We gave you an introductory presentation on October 12. I'm not going to go through this in detail, but just a reminder that there are two processes that the one care Vermont ACO is subject to certification, which is one time with a annual eligibility verification and then budget review, which is annual review and approval or modification. And it's actually a bifurcated process. So payer contracts are still under negotiation. So this is the expected budget as things stood when it was developed over the summer. We actually have the ACO come back in the spring with finalized contracts and present their final budget. And again, a reminder of the standards of review. The statutory criteria or in the reference slides at the end of the deck are available online. If you want to look through those, these are budget specific criteria that I'm showing here. So again, it's 18 BSA 93 82 GMCB rule five and elements of the all payer ACO model agreement. And specifically the board considers any benchmarks that are established under section 5.402. We'll talk about that a little bit, all of the criteria and elements of the ACO pair specific programs and any applicable requirements of 18 BSA 9551 of the Vermont all payer accountable care organization model agreement. And the ACO shop the burden of justifying its budget to the board. So our staff is a very familiar and has gone through a deep review, but sometimes there are questions that we need to defer directly to the ACO to have them speak for themselves. Quickly show you where we are. Excuse me in the process. Today we're at the staff analysis presentation. There will be two opportunities for deliberation as needed. Next Wednesday and December 14, as well as December 21, where we will notice a potential vote if the board is ready to do that. The ACO doesn't need its budget established by the end of the calendar year and then again in the spring they come back and present actual budget a reminder that public comment is accepted throughout the process starting in October. We request that comment be submitted by December 16 so that we have time to review and compile it prior to the final recommendations. We have received some recent you know within the last day or so comments. We have done our best to incorporate those into the slides, but we are still still working to incorporate you know information that came in at the last minute and the comment period remains open. So I'm going to turn it over to Jennifer de Paldo to go over an overview of a public comment received. Thank you, Marissa. Can you hear me. Yeah, great. So the board has received a total of 19 comments as of December 5 and like Marissa mentioned, I just want to remind folks again they can still submit public comment related to one carers fiscal year 2023 budget submission. And we do ask that you submit by December 16 in order to be considered ahead of the board vote, which we have scheduled tentatively for December 21. The board has received comments from a number of stakeholders that identified affiliation, including hospital CEOs, federally qualified health centers, primary care providers and members of one carers board of managers. And common themes from these comments include the value of one carers data analytics, population health initiatives and transition to value based care, and the value of care coordination and strengthen partnerships with local care organizations. And among the comments received from members of the public who did not indicate any affiliation. The common themes were concerns related to the transition of one carers data analytics to the UVM health network and concerns related to measures of one carers performance and overall value to Vermont's health care system. And you can move ahead. Great. Thank you. So, following one carers budget hearing on November 9, one carers board of managers submitted a comment regarding topics that were addressed during the hearing. One carers board of managers sought to clarify how one carers executive compensation is determined and provide comment on the board's approach to executive compensation in the hearing. The use of the term data breach when referring to the cyber attack that occurred at UVM MC in October 2020. The standards and legal requirements that were considered regarding one carers new data analytics arrangement with UVM health network. And the manner in which one carers operational costs are funded. One care does state that operational costs are not funded directly through taxpayer dollars, but through hospital participants in one carers network. The board also received public comment from the healthcare advocate and under statute the HCA has a right to participate in the board's review of the ACO budget by submitting questions. The board will ask the ACO submit submitting written comments to the board and asking questions of board staff and asking questions and providing testimony in any ACO budget hearing. These from the HCA include concerns regarding one carers deepening ties to the University of Vermont health network, specifically that it risks undermining the effectiveness of Vermont's all payer model. And one carers continued lack of demonstrated benefit to Vermonters in the state. The HCA points to insufficient evidence to support claims that their programs improve population health outcomes care coordination for Vermonters or reduce costs. I want to note that one care submitted a response last night to the HCA's comments and the responses posted on the board's website for reference. Again, there's still opportunity to submit comment to the board before December 16th to be considered ahead of the board's vote. Thank you so much. I will turn it back to Marissa. Thank you, Jen. I'm going to give a high level overview now of the staff analysis and what you're going to hear today. So the high level overview, sorry, this is actually a high level overview of the of the ACO's budget in general, just to ground everyone. I'm going to talk briefly about their provider network, payer programs, their income or financial statements, and then our approach to the FY23 staff recommendations. So on the provider network, the changes to the provider network are minimal this year. They're, they noted in their narrative some changes, addition of independent primary care, oh, sorry, one primary care practice closed through retirement. They've added four skilled nursing facilities. They've increased payer program participation, including one CCR practice. You can see kind of the high level overview of their network there. I will note, as we use this figure last year, we had to update it based on the underlying calculations that approximately 82% of Vermont primary care providers do participate in one care network according to estimates derived from their roster, as well as information from the Department of Health Workforce Survey data. One Care's participation data is available in the budget submission and posted online for their provider rosters and participation by organization's payer program. But overall, the changes are minimal this year and without putting a quantitative number on it except for that 82%, there's pretty good saturation of their network within the system. For payer programs for 23, this is a summary of starting attribution and payer program participation by hospital just to give you an idea of the scope. Again, this comes from attachments A and B of the one care budget submission. And this is to show you that we have 14 HSAs participating overall, how many HSAs are participating in each payer program and then broken out by the type of hospital. So the overall sort of takeaway here is that, you know, there's lower participation in Medicare, particularly for the critical access hospitals. The penetration is higher in the other programs. So we just broke this out by type of hospital this year. And the numbers on the bottom are so the overall HSAs and, you know, of seven participating critical access hospitals overall, how many are participating in each payer program. Same thing for the acute care hospitals and then the two participating academic medical centers, University of Vermont Medical Center and Dartmouth. Okay, this is a summary income statement view. So the big numbers in one care submitted budget. We look at the budget in two ways. The full accountability or total cost of care budget information is in purple. The entity level or organizational level budget is orange. So let's take a look at the full accountability budget first. The full accountability submitted budget is the result of provider network participation, negotiated payer program terms and one care strategies to develop their network payer programs. So the full accountability budget includes healthcare spending for one care attributed lives for total cost of care services process externally to one care. So that's 97%. These are, this is dollars that would be spent on this particular population, regardless of, you know, regardless of one care participation in one care, this represents the amount that's expected to be to be spent on this population. About 2% of that full accountability is population health expenses or dollars that have been diverted to population health payment models or programs. And 1% of that represents the administrative expenses that it takes to run one care and perform all of these functions. The full accountability budget is reviewed and approved by the one care board of managers, but one care cannot unilaterally decide contract terms with payers, such as payment models, benchmark, trend rates, risk arrangements. Many of the factors that contribute to this budget are based on negotiated arrangements. The entity level submitted budget is developed at the discretion of one care governance and leadership, meaning it is elements of the budget. They're not contractually obligated. And are developed through committees made up of the provider network supported by one care staff and leadership and improved by their board of managers. So all this happens before the budget comes before the green mountain care board. Revenues that are not contractually obligated with payers include participation fees, a fixed payment allocation, which also comes from hospitals as an offset and shared savings distribution, which is set in policy by one care. Expenses include population health management investments or a portion of them administrative expenses and shared losses, if any, again, this is set in policy. Now you won't see the shared savings or losses in the budget because one care budgets as break even so they budget to hit their targets exactly, including the advanced shared savings to fund the blueprint, which we will talk about later. Okay, so this is meant to be a flow chart to help you understand the one care budget in the context of the full landscape of Vermont health care spending. So if you start on a key chart on the left, you have a total Vermont resident expenditures from the it's 2020 data. So first of all, this is very, it looks nice. It's beautiful. It's very back of the envelope, though, because we have different years we have 2020 expenditure numbers and then we have one care budget numbers but I think it's enough to give you it give you an idea so on the left. You have Vermont total resident expenditures, estimated at 6.4 billion. So first of all you peel off 56% of that are not even under the all payer model. So that's the bottom amount 44% of that total is included in the all payer model total total cost of care. So then you look at that amount and off the top you peel off non one care Vermont that's about 51% of that. And the the next darker green bar is the one care Vermont total cost of care plus population health. So that's about 49% of the all payer model total cost of care. And then you drill down from there the one care budget specifically the dark green to the to the two orange. You have about 32% is converted to fixed perspective payments under the different pay arrangements. The rest of it is fee for service, linked to quality. And we can can talk about what that means a little bit. So we put some numbers to that. Again, as we, as we stated or stated in the previous slide the total cost of care that's the 1.4 billion. And this is the portion of the Vermont total cost of care that one care is accountable for affecting change on so lowering the rate of growth and improving quality. So that piece that says one care total cost of care that that's their sphere of influence. This is the expected health care spending that would be spent on the population of patients absent any intervention and all of this except for all of this except for the administrative expenses go directly to providers to pay for care. Some of it is contractually obligate or most of it is contractually obligated some of it is at the at the discretion of one care 438 million is converted from fee for service to fix perspective payments in some form. And the rest is converted from fee for service to fee for service tied to quality. Meaning they, if they, if they don't, the payments are lowered if they don't get certain quality targets. And then one care Vermont population health and admin their total accountability budget that comes to 45.1 million 29.9 is in population health payments for providers. And is a conversion of funds from hospitals or payers to primary care or community based providers so it's, it's, you know, revenues that may have been paid to to hospitals are sort of being converted into to primary care. So it's trying to funnel more more dollars into primary care payments 15.2 is administrative or as one care spoke about it shared infrastructure for administering these payments and program. One more contextual slide for you here so this donut chart shows you administrative costs this is to help you contextualize that that $15 million in relation to the total cost of care. administrative costs associated with insurance were 8.3% of total Vermont resident expenditures in 2020. So insurance administrative costs are considerably higher now they also do a lot more but it's just meant to give you some context on what it costs to administer the payments and programs. So many of the ACO expenses are not new but rather reallocated from payers in hospital so it's difficult to gauge how many of their expenses are truly new to the system spending so some of their functions would be reallocated back to hospitals or insurers if they didn't exist. And what we don't have today is a PMPM from payer for their care coordination activities that is something that could be considered for additional in a rate review to support regulatory alignments again this slide is contextual to, you know, link what some of these numbers mean in our other other functions. So one more contextual piece is administrative costs are about $44 per member per month for QHP plans for example and about $6 per member per month for one care. I think it's important to make a quick note about COVID-19 public health emergency as a factor so the COVID-19 public health emergency has created unique uncertainty for providers ACOs and payers in designing and implementing value based model so this includes volatile utilization patterns impacts on quality measurement linking results to performance and financial uncertainty. So we just need to keep that in mind when we are assessing results. And note about the approach to the FY23 recommendation. So in FY22 or last year's budget order, the conditions reflected a focus on data driven monitoring and oversight with a focus on ensuring that the ACOs management drives continuous improvement consistent with a high performing ACO and then supports achieving the state's health reform goals. Now much of this board is new so you weren't here for that process but I know that you're familiar with those materials but we wanted to note that we're continuing a multi-year approach here and I know both board members and the public have referenced some of the materials that were presented last spring on core competencies for high performing ACOs and recommendations that accompanied those. So this was envisioned as a multi-year approach to be revined in 2023 through this budget review and then also an FY24 guidance development process. So the staff recommends continuing to strengthen this approach over the coming year, keeping data driven ACO performance monitoring at the center of our ACO oversight. And we will talk more about that as we go on. So that's the high level overview. I am going to now start to dig in to our key areas of review and they include certification and a review of the data analytics transition, ACO budget and financials, total cost of care and trend rates, payer programs and risk model, payment models and fixed perspective payments as well as the comprehensive payment reform program, population health quality and model of care, performance measurement improvement and results to date. And I'm going to turn it over to Russ McCracken for a discussion on the certification. Thanks, Marissa. Sorry, this is Russ McCracken, staff attorney for the board. First off and for the record, I want to thank Michelle Sawyer for leading the certification review and doing most of the work on putting together these slides and the staff's memo on certification. I'm presenting in her absence today, but want to make sure to credit her. Under GMCB rule 5305, a certified ACO must annually submit to the board of verification that the ACO continues to meet the requirements for certification under statute and rule. The ACO must also submit to the board any material changes and policies, procedures, organizational structure, provider networks, health information infrastructure, or other matters that are covered by the certification requirements. One care is currently the only certified ACO in Vermont. It was certified by the board in 2018 and has continued to be certified since then. Procedurally this year, the board issued a certification eligibility form to one care in June. One care submitted that form to the board on August 31. And one care also provided responses to the board to some follow up questions from board staff on October 14. Both of those are available on the board's website. What you see before here is an outline of the rule requirements for certification. There will be a memo from staff covering each section of the rule, so I don't want to go through all of these today. But instead, I want to highlight and review a couple of areas where there have been follow up questions and particular interests. So, good. Thanks, Marissa. On executive compensation, some background. The board issued guidance in May of 2021 regarding executive compensation under rule 5203. This section of the rule states that an ACO must have a leadership and management structure that aligns with and supports the ACO's efforts to improve quality of care, improve population health and reduce the rate of growth in health care expenditures. The guidance adopted by the board says to comply with section 5203 A of the rule, an ACO must structure its executive compensation to achieve specific and measurable goals that support the ACO's efforts to reduce cost growth, or improve the quality and overall care of enrollees or both. So, based on information provided by one care, one care has corporate goals that align with their strategic plan. The variable pay is a component of each eligible employee's total compensation, but is only paid if the ACO and its employees successfully achieve these goals. Next slide please, Marissa. So here are the variable pay percentages for one care for 2022. For each employee, the variable pay is determined according by the next level of management in one cares corporate structure. And then by the one care board of managers for the one care CEO. I'm going to pause just to make a note here, because it's a question that comes up from time to time. The one care board of managers composition is subject to requirements set by GMC be in rule 5202. And also one cares operating agreement provides a detailed provides the details of the composition of the of one cares board of managers. 75% of the control of one cares board is held by ACO participants. Their board has to include at least one Medicare beneficiary, one Medicaid beneficiary and beneficiaries of commercial insurers. So when we look at the composition under one cares operating agreement. There are three managers appointed by UVM health network as sole member of one care. And then there are elected managers, the insured beneficiaries that I just mentioned, and then managers representing providers, including one nominated by an academic medical center in Vermont. And total there can be up to 21 managers on the one care board. But I believe the current number is 19. So. Provide provide that as some background and reference. So here the 2022 goals that are provided that were provided to board staff by one care. I can review them quickly. I don't want to read through all of them, but these are the goals for the basis of variable pay. Including goals to improve payment reform by involving it evolving and enhancing payment reform programs. Improve their network performance to ensure a high quality equitable system that continuously strives to improve healthcare delivery and outcomes. And then deliver and implement an ACO data strata data strategic plan. So these, these were the goals that one care provided us for the basis of awarding variable compensation. These were 2022, but the focus of 2023 goals. One care set would also be consistent with their strategic plan. And my understanding was expected to be similar. So we can go on to the next slide here. Decision support tools under rule 5, 206 I and ACO must apply or support participants to apply. Enrolling caregiver shared decision making tools that enable enrollees to assess the merits of various treatment options. Staff explored this area in greater depth this year as it was identified. As an area of interest in previous years. The tools reported as fulfilling these requirements. We could say we're more care coordination tools. Then tools or methods that enable patients directly to assess treatment options in the, and the risks and benefits involved in a particular course of treatment. One care was supported that it was not a clinically integrated organization and it offers a collaborative opportunities to providers. Where education of evidence based practices can be communicated and shared. And then providers offer decision support directly to the patients. One care is supporting the participants and applying the decision support tools. You know, similar methods for clinical sharing and decision making. In that in that structured in that way. So we can go on to the next slide under rule 5 to 10 there are health it requirements for an ACO to meet. And I think when one care submitted certification materials this summer, there were details related to. The new analytics platform that we didn't have. So, let me just put a pin in the slide for a moment and come back to it in. Come back to this topic in a couple of slides. So, in terms of. Board action on certification. Consistent with our past practice. The GMC B does not need to vote. In order to continue one care certification. The staff. Are preparing and we will send around a. Memo to the board and it will be made public also, I believe, covering that. In more detail, the specific elements of. What cares continued eligibility for. Certification under the rule. Board action would be needed on the other hand, if the board were to. Conclude that 1 care no longer met some requirement. To be eligible for certification. And in that case, the board would provide notice to the ACO. An opportunity to respond. Before requiring the ACO to take some sort of corrective action to. Remedy, whatever that deficiency or shortcoming was. There's a process set out for it for that remedial action in the rule. I won't go through it now, but. It's. Established and it. Gives the ACO. Plenty of opportunity to know what the perceived deficiency is and. Respond to it. So next slide, Marissa. This is somewhat under. Certification somewhat under budget review and somewhat under neither. So. Went to look specifically at the. One cares plan transition of its data analytics. Platform to run through the university of Vermont health network. And give the board a. Adjusted process approach here. So further review of the, the 1 care transition. Could be addressed in FY 23 budget process. But the analytics transition is not necessarily a part of that. Budget process. 1 care informed the board. In the summer. Prior to submitting its budget of the transition plan. And. 1 care and. UVM HN signed a contract. In. The fall here, not too long ago prior to. You know. Completed review and approval of the FY 23 budget. So. Well, the transition has an impact on the sources and uses of. 1 cares FY 23 funds. 1 care did testify that the transition is overall budget neutral. So further review of this arrangement could be done outside of the FY 23 budget process. Under the board's monitoring authority and rule 5, 5, 0, 3. So under rule 5, 5, 0, 3, the board may use any and all powers granted to it by law. To monitor an ACO's performance or operations, or to investigate an ACO's compliance with the requirements of this rule. Other applicable laws or regulations and decisions and orders. Of the board. And there's a. Process set out in the, in the rule that. Says reviews can be performed at any time. It's not limited to the budget process. And to conduct that. So further review or monitoring of the ACO's operations, the board would. Advise 1 care of the specific areas that are being reviewed in any statutory or regulatory provisions. Under examination. And we're suggesting that the board move. Any additional follow up on this arrangement or further monitoring of this arrangement. Outside of the FY 23 budget process. I think that allows for additional questions, review, ongoing monitoring. This approach also allows the board to. Monitor and sort of ensure, for example, that. Appropriate safeguards against sharing of competitively sensitive information are in place and being followed. You know, on a going forward basis. So. That is our suggestion. I do want to be a little bit. Careful or particular in talking about the analytics transition. One care testified that it was budget neutral. In reference to the total amount. Spent by 1 care. But the specific uses of funds. They are impacted in the FY 23 budget by the transition. So inherently there is that. Aspect of the transition that is part of the FY 23 budget. Notwithstanding that our overall recommendation is. To move the. Further any further review and monitoring. To a separate to a separate process, not. Specifically tied to the FY 23 budget. And so next slide. I think with that, Marissa, I'm turning it back to you. Yes, I'm going to turn it over to our financial analyst, Matt Sutter. Good to go, Matt. Hang on just a minute. I think he was having a technical issue with team. So let me just check on that for you real quick. Sorry, can you hear me now? Sure can. Apologies. Tech issues even in the office. So I'm just going to be reviewing one cares budget and financials. We can go to the next slide. This is just. So as Marissa mentioned at the start. We kind of look at the budget in two ways. One is that the budget includes all expenses, including utility and entity level. I won't repeat what she said, but just to reiterate the full accountability budget includes all spending for attributed lives for total cost of care services. Population health expenditures and administrative expenses. By contrast, the entity level or gap budget only includes elements, which one care through its government structure has to scratch it over. So that is not contractually obligated. We sometimes use the 45.1 million dollar figure when discussing their entity level budget. It's not necessarily discrepancy. What they're doing is taking the 25.5 million that we're discussing and including the full value of the population health management based payment blueprint and sash funds. So it's slightly different, but it's largely looking at the same thing. We can go to the next slide. And this is the same slide Marissa presented earlier. Just giving a rundown of what the full accountability entity level budgets look like. I think we can move to the next one. So here you'll see their full accountability. Let me back up for one second. So the way we're going to go about presenting this is we're going to look at a full accountability budget first. This high level overview or get summary statement includes income and expenses. And then on the forthcoming slides we'll look at revenue separately and expenditures separately. So here you can see their submitted FY23 budget includes an additional $95 million over FY22. While there's some growth in small growth in FPP, this growth is largely a result of $92 million increase in that external total cost of care. As you can see at the top line. Beyond that, I think we can kind of look at administrative revenue ratio down at the bottom. It's pretty consistent from prior year. And that's just looking at a proportion of their operating expenses to their overall expenses. And similar with the phm ratios and with and without blueprint. Moving to the next slide. Looking first at the revenue side. Just you can see a visually. And in the table that the growth is largely as I mentioned in that total cost of care. I would also like to draw your attention to the other revenues line since the label might be slightly confusing. These are their fixed payment offset. Like participation fees. These revenues come from hospitals, but through a slightly different mechanism. We can move to the next slide. Not a whole lot to say on the expense side. You'll see a similar story here. That top line external health care spend growing. The majority of the growth here. There's. As Russ mentioned, there's movement within the operating expenses below. No, it's relatively neutral. I think we'll save that discussion for the entity level budget because I think it makes a little bit more sense contextually to discuss it there. We can move to the next slide. Just visualizing that like the growth. The revenue changes here. You can kind of see just the scale of the total cost of care to kind of dwarfing everything else. Basically the same information from the previous slide just kind of presented in a visual format. We can move to the next slide. And this is if we just looked at that total cost of care growth at 92 million. This is like a reconciliation of that component. So we're kind of just drilling down into that $92 million increase within that. You can see nearly $18 million reduction in Medicare revenues being offset by increases in Medicaid and private payers. Next slide please. And here we're looking at the population health management, expense reconciliation. While the total of PHM is only increasing by about $800,000 and that there is some movement within that line item. So we just wanted to break out the individual components of that. These changes reflect the shifting to a new PHM payment model and a phase out of some program support, which Marissa will discuss in the population health section. And the next slide just shows, I wanted to show the breakout of the base and bonus PHM payments by provider. The gosh, they're all kind of similar colors, but the darker blue, I guess, blueish green on the left is FY 22. The middle column will be the base only and then the column on the far right is the base and the bonus potential by provider type. I think we can move to the next slide. Switching over to the entity level budget. This is, as we mentioned, only looking at gap revenues similar to what you'd find on their audited financial statements. The entity level budgets fairly stable. It's increasing only about 2% from the prior year. And because of this, if you see the ratios at the bottom, they're staying relatively stable as well. So there, you can see a slight increase in PHM ratio relative to the administrative ratio. The next slide. I mentioned it, I think, briefly on the full accountability revenue slide, but I think it jumps out a little bit better here. The $5 million in other revenue or $5.6 million in other revenue, you can see growing from 4.6 in the prior year. And let's see. Well, it's only increasing just under about $500,000 net in a relative sense. You can see a slight shift from participation fees to the fixed payment offset that other revenues line. And next slide, please. Here's the expense side of their entity level budget. I think in prior years, we had just one line for their operating expenditures. This year, I think we decided to break it out a little bit better just because there is that movement with the analytics piece to showing the salaries benefits contract purchasers to software and other revenues on the summary statement. And as discussed, there was some shift there due to the analytics change. This is just illustrating what we discussed a couple slides back. So the revenue for their entity level budget entirely comes from hospital revenues. And what you're seeing here is like a slight decrease in participation, about a half million dollar decrease in participation fees and about a million dollar increase in that other revenue, that fixed payment offset. So netting out about a half million dollar increase to their entity level budget. Next, thank you. So this is similar to the population health management slide we showed in the full about accountability section, but just focused on the gap component to the changes to the THM programs. Again, Marissa will be discussing the programmatic changes in greater detail. But just wanted to provide some visual way of kind of doing the changes. And one of the major changes this year is the shift has discussed the analytics to contract with UVM. While the shifts net neutral, there was some movement between the lines within operating expenses to account for this. You can see movement here, like net movement in those lines. But it's worth noting the changes above aren't entirely the result of the analytics change. I can give, there's some other ones that did that. I'll give an example of the benchmarking item was included in software in FY 22. But in FY 23, it was moved to purchase services. So there's some small changes like that movement occurring there. One care provided the board with a more detailed breakout of these changes. But some of the figures involved confidential information. So just provided a kind of high level overview of the changes here. And this slide shows just looking at operating expenses, kind of the concentration among those four categories. So you can see the contract and purchase services growing considerably. And salaries and benefits decreasing, you know, as a proportion of their total operating expenses. And this is just largely reflective of that analytics shift that we discussed. So kind of key takeaways. Growth in their full accountability budgets, largely driven by external health care spend. As mentioned, you're seeing some decrease in Medicare revenues being offset by increase in Medicaid and private payers. The shift in analytics to a UVM contract as one care testified is net neutral, but for some overlap in services during the transition. And one care's overall operating expenses are relatively stable down just about a percent half from FY 22. And so our recommended approach is to require one care to notify and agree on care board of material changes to their budget, explain the variance, require one care to submit a revised budget by March 31st, and present a revised budget in April 20, by April 23, including final pay, you know what, I won't read this whole thing. It's consistent with last year's, I think the some additional language as Ross noted about regarding evaluation and reporting costs. And consistent with prior years collecting audited financials in 990s and through the ACO reporting manual. And I think that does it. So I will pass it over to Sarah who I think is, believe us next. Thank you, Matt. Can folks hear me? Great. Okay. So I'm going to be walking us through total cost of care TCOC and trend rates and then after that also the payer programs and risk model section. Next slide, please. So this slide once it comes up, there we go, is going to, it walks us through really how's the trend, so the rate of increase and the benchmark, the ACO total cost of care spending target within each payer program set. So for Medicare, GMCB has a big role in that more to come on that next week's board meeting. For Medicaid, Diva and one care can negotiate a benchmark. Actuaries involved in that process and the board reviews this through the Medicaid advisory rate case process. And then for the commercial pairs, it's really a negotiation between each payer and one care in terms of the trend and the benchmark and the programmatic components. We do want to note that the board's rate review decisions are one component since that process does cover the medical trend for each filing. So this is kind of summary of where does the board have levers, who has levers to decide these things. Next slide, please. This table shows the expected total cost of care, so the program benchmark for each payer program along with the budgeted trend from the base experience. The key thing to note here is that the base experience is not the same as projected FY 22 total cost of care, that green column. So we wanted to kind of set that aside. Most programs calculate the benchmark based on historical spending for the projected attributed population, which will vary between performance years. And they also need to look back farther than just the prior performance years since FY 22 data is still happening, still incomplete. So these trends, you can't go from the green column to the trend to the FY 23 column. We just want to make that really clear. So the next slide, thank you. The key takeaways in the total cost of care and trend rates section is really setting the financial targets is still really hard. The pandemic has had some big impacts on what makes it so challenging for those targets. And we'll be discussing the implications of those trend rates and especially the Medicare trend for all-pair model agreement total cost of care, so the APM, TCOC measure targets at the December 14th presentation and staff recommendation on the Medicare ACO initiative benchmark. So we'll get to hear more about that from Sarah and Lindsay next week. Next slide. So the recommended approach here is to require to implement the benchmark trend rates from the payer contracts in alignment with the Board's decision on the Medicare ACO benchmark with the Board's Medicaid advisory rate case and finally for commercial payer contracts in alignment with the ACO attributed population and the Board's approved rate filings. And that is very consistent with past years. Staff may also recommend requiring additional information from OneCare to support a better understanding of what commercial payer data is available to OneCare during the trend and benchmark negotiations to kind of build on what we've done in past years to requiring actuarial certification of those trend rates. Next slide. So now we're going to move on to a summary of the payer programs and the risk model. In this section we'll be walking through a summary of OneCare's risk model for each payer program, total risk by HSA for both the risk-based entities that's the hospitals and primary care providers and discussing the processes for distributing shared savings and shared losses across the provider network. Marissa's reading my mind now. Thank you. So a little bit of background on the risk model. OneCare Vermont assumes risk from payers in their payer contracts to care for a particular population as specified. These contracts do not specifically distribute or specify the distribution of shared savings or shared losses to the ACO provider network. That is something that OneCare designs and implements in their agreements with their provider network. So payers and OneCare decide together how much total risk there is, but it's OneCare and their providers that decide how that gets spread across the network. We're going to talk through the second aspect of that a little bit more. I do want to remind folks that these analyses are based solely on OneCare's budget submission. So many of these contracts, all of these contracts are not yet final to my knowledge at least, which is why we have not reviewed them yet and we'll have more to say on that in the spring once those contracts are negotiated. And I should say Medicare and Medicaid contracts are usually finalized by the end of December and are required to be in effect, or right around the end of December, and are required to be in effect for January 1st. Those commercial contracts often are not finalized until early spring and usually are presented with a revised budget analysis. All right, the table on the next slide briefly describes the payment models, risk arrangements, and tied equality in each of OneCare's payer contracts. I won't read through the table, but instead just want to highlight that OneCare has budgeted for their risk corridors to increase by one percentage point in the Medicare program and both the Medicaid traditional and expanded risk models. So up to 3% now for Medicare and the Medicaid traditional cohort and up to 2% in the Medicare, excuse me, Medicaid expanded attribution cohort. Quality remains a component of settlement calculations for all payers and for Medicaid, also a component of the population health model payments for that payer. Commercial arrangement, risk arrangements are redacted here. Those are confidential. So Marissa will dig into the payment models in a later section, but this table just kind of includes a quick overview to show how those can relate to the risk model. On the next slide, we are looking at so we've got these risk arrangements, these risk corridors. How does this add up to total cost to total risk? I borrowed this chart from OneCare's slides to show how total risk across payer programs has evolved since the original 2020 budget submission, so the pre-COVID budget submission, showing here that there was a huge decrease in risk after the pandemic kit, and we're just now getting close to hitting pre-COVID levels. So for FY23, we're looking at 36.5 million total risk. The next slide digs into that a little bit more deeply. This slide shows the budgeted risk from 2019 to 2023, so going back a little bit earlier, one year earlier, as well as the percentage of risk held kind of at the OneCare entity level versus delegated to the provider network. This budgeted risk is worth showing because it's the risk level that OneCare was planning for prior to the onset of the pandemic that's referring to the 2020 pre-pandemic column. Again, OneCare has brought that total risk level back much closer to pre-pandemic levels for FY23, but that said risk relative to total cost of care is still a smaller proportion. One thing that I want to highlight here is that the OneCare held portion of risk is also quite a bit lower than in pre-COVID years. For context, OneCare typically has taken on risk as a glide path to support health service areas who are newly joining payer programs but not quite ready for the full risk level in their first year. Since we're calling out OneCare held risk, we also want to call out OneCare held net assets and equity, which also includes a reserve of $3.9 million that the board required in its 2019 budget order as well as net assets. OneCare also, we want to note, has a $10 million line of credit as required in their contract with Medicare. So how is this risk? How are any savings or losses distributed throughout the OneCare network? OneCare has a couple of major policies and procedures that I'm going to walk through briefly because it's in these policies and procedures that OneCare documents how these incentives are passed down to the providers in their network. So first, the program settlement policy outlines what happens to dollars at settlements. So savings to be paid out to providers or dollars to be collected from providers to cover losses. As these slides show, this includes $1.50 p.m. p.m. of first-dollar shared savings and shared losses for primary care practices through what's called the primary care accountability pool. This was in existence last year. So this will remind folks who saw last year's presentation a lot of the FY22 budget. And we'll dig into that a bit more deeply on the next slide. If OneCare achieves savings and there are remaining savings after that $150 p.m. p.m. excuse me, they are split 90-10 with 90% going to participating hospitals referred to as risk-bearing entities and the last 10% going to high-performing health service areas through a performance incentive pool, which we'll also cover a little bit later. Some dollars can also get pulled out to fund OneCare expenses that are approved by their board of managers. So on the next slide, we go a little deeper into the primary care accountability pool and performance incentive pool. Rather than walk through the mechanics as they're described here, I think the most important things to note are that of that 1.6.5 million in total risk OneCare has budgeted for 3.7 million, so just over 10% to be held by primary care through the primary care accountability pool. This is an increase from 2022 when primary care held 2.4 million in risk. However, it accounted for a bigger share, about 15% last year and this year a little bit lower 10%. The performance incentive pool rewards high-performing HSAs based on year-over-year PMPM and avoidable ED visits, so year-over-year change in those two measures. The total amount of the pool depends on the amount of shared savings achieved, so it's not something that we can really provide an estimate for. So on the next slide, we go even a little bit deeper into that primary care accountability pool and how risk and savings are split across primary care and across, excuse me, split between primary care and each health service area's risk-bearing entity. So of that 36.5 million total, non-hospital primary care providers are carrying 2.1 million while hospital primary care is carrying about 1.6 million. The RBEs are carrying the remaining 32.8. Down at the bottom of this table, I have shown kind of how this works out in terms of the proportion of total risk, noting that this does not quite add up to 100 due to rounding and I think one key takeaway that we can draw from this, if you do a bit of quick math, is that hospitals in the UVM Health Network, so CVMC UVM Medical Center and Porter collectively hold 17.3 million of the risk held by the hospitals, so of all the hospital-based risk, 52%. When we add in hospital-based primary care in those regions, there's 50% of all risk in the ACO Network. So in the next slide, we've been looking ahead to 2023. Right now we're going to take a moment to look back to 2021. This slide summarizes the 2021 settlement for one-cares payer programs, so the shared savings they received, the shared losses they were required to pay, which was also presented at the November 22nd payer panel. Again, this risk was distributed to one-cares providers according to their policies applied to 2021. So on the next slide, before we wrap up this section, I do want to spend a little bit of time talking about the Medicare contract and specifically what's known as the advanced-shared savings component. So of that 36.5 million in risk, $9.5 million comes in form of the Medicare advanced-shared savings. And this goes all the way back to the beginning of the all-pair model agreement. Vermont had previously participated in a Medicare demonstration called the Medicare Advanced Primary Care Practice Demonstration, the MAPCP demo, which allowed Medicare to join into the BluePurve for Health and kind of associated programs, so PCMH, CHT, and SASH payments, and to join into Vermont's payment model and contribute as a payer to Vermont's model. This effort was evaluated very successfully and the all-pair model agreement includes provisions to allow Medicare to continue to contribute those, to really foundational programs in Vermont by providing the ACO with an advance against any future shared savings. So that funding is attached to the Medicare benchmark as a manual adjustment, so whatever the advanced-shared savings amount is, it kind of started as one amount has been trended up every year, this year 9.5 million is budgeted. That amount is added to whatever the Medicare benchmark would otherwise be, but it doesn't really represent performance risk. The advance is reconciled at settlement, so if one care doesn't save more than the advance amount, they'd be required to pay dollars back to Medicare. But the benchmark itself, the goal is higher than it otherwise would be. So this was kind of the way that Vermont could continue to receive these funds, continue to have Medicare invest in these important programs. But that's it. ACO providers have expressed that they perceive this as an asymmetric risk corridor, even though it's accompanied by that bump in the benchmark itself. And this is something that, again, will get covered a little bit more next week when we talk about the benchmark, when the board hears from staff about the benchmark. But we're telling you this because one care is taking on risk from payers, including from Medicare as an ACO, and they decide how to delegate it. So next slide, wrapping up this section. Key takeaways are that the total budgeted FY23 risk and reward, again, $36.5 million. The one care held risk is a very small portion of that total risk, and it's decreased both in dollars and percent of total risk over time. The primary care accountability pool is pushing first dollar risk and potential reward to primary care practices according to total attribution. The total primary care accountability pool for FY23 is budgeted at, apologies, there's a typo here, $3.7 million, 10% of total risk. And primary care about accountability pool for non-hospital owned primary care, so for independent primary care and FQHCs, is $2.1 million. And excuse me, there's another typo here that should say, FY23 budget. The performance incentive pool sets aside 10% of total shared savings after that first dollar $150 PMPM to reward high performing HSAs based on these two measures that we discussed. And finally this kind of rehashes the advanced shared savings information that we just discussed. So finally the recommended staff approach here a lot of this is consistent with past years, and there's also some that's new. So consistent with past years to the extent possible we would like to require one care to develop and engage in scale qualifying payer programs and where this isn't possible to provide us information on you know, what makes it not possible and why. In addition as an FY22 we recommend encouraging one care to pursue payer programs with Medicare Advantage plans particularly those that are operated in Vermont. Later in this presentation Michelle degree will review using will review Vermont's utilizing Medicare Advantage enrollment. So spice to say it's growing really really rapidly which drives home that this is going to be a really important area to watch in the next couple of years because MA plans have not historically had payer contracts with one care or other Vermont ACOs. That said we've received feedback from one care and from these payers that these plans the Vermont based plans are still really young and that developing new ACO payer contracts may not be feasible while enrollment is still not stable. So recognizing these factors which I think are reasonable we do want to continue to push for alignment here so we're recommending establishing a two-year target for 2024. Next consistent with past years we recommend requiring one care to implement the ACO risk model as described and notify the board of any changes and finally a new condition staff plan to recommend that one care as an organization hold risk for the Medicare shared savings amount rather than delegating that risk to the provider network. This would mean that if savings in the Medicare program were insufficient to cover that advanced shared savings amount that 9.5 million one care would have to cover the different without passing that risk on to the provider network. As described earlier this really is not performance risk which is why we feel it shouldn't be passed on to providers. Earlier we also reviewed one care's net assets and reserves. Obviously they are less than the total advanced shared savings amount at the moment so if this is a condition that the board pursues one care would need to strategize about how to cover this amount in the event that they need to pay some or all that amount back to Medicare and Sarah Lindberg will talk a little bit more about this again next week. And with all of that said I am going to pass it on to Marissa. Thank you so much Sarah. I'm going to move now to a discussion of payment model mostly focused on fixed perspective payment and comprehensive payment reform program payments. This is a contextual slide that we used last year with a nice visual for your reference showing funds flow and how dollars flow through the ACO from the payer to the ACO, the ACO to providers and payers to providers. I'm not going to walk through all this but I think it helps to contextualize how the payment works and we borrowed this visual from the first University of Chicago NRC evaluation that is posted on our website and what I'm going to discuss here is looking at the proportion of total payments which are value based and proportion of total payments which use a fixed payment or population based payment. Okay, so the takeaway from this slide is that the proportion of fixed perspective payments to overall total cost of care has remained relatively stable over time and you'll see on the later slide that's roughly around 30%. The fixed perspective payments here that I'm talking about include all things that are called a fixed perspective payment whether they are reconciled or unreconciled and what that means is Medicare, the Medicare fixed perspective payments also known as the GDPP or all inclusive population based payment is an upfront payment to providers but it is reconciled at year end to the fee for service equivalent. So this is often discussed as sort of being perceived in effect as the same thing as fee for service however it does provide a cash flow mechanism and it is considered a fixed perspective payment for our purposes of reporting this the mechanism is different. The fixed perspective payment in the Medicaid program is an unreconciled payment so the upfront payment is the amount and it's not reconciled to fee for service at the end of the year. The blue cross blue shield fixed perspective payment pilot is reconciled and that's a small pilot with one hospital so all of those payments that I just discussed and the comprehensive payment reform payments are in that kind of light green bucket. So the comprehensive payment reform program or CPR is a pair of blended fixed payments for independent primary care practices for poor primary care services plus additional and additional per member per month for non-core services. CPR payments are fixed for the primary care practice but they are reconciled back to fee for service and settled with the HSA risk bearing entity so they are reconciled at the primary care practice level so it's a true fixed payment primary care practices but since there is not an unreconciled arrangement with the payer those payments are reconciled at the hospital level. This chart is meant to show you the growth in the CPR program year-over-year we get regular reporting from one care on this program so from 2018 to 2022 and sorry if it's really small but this represents the funding revenues so the larger proportion of it is that payer blended contract revenue and then there is a hospital funded investment in this program as well so that represents a redistribution of funds from hospitals to independent primary care practices and then on that I have growth of attribution in the program overall so lives in this program which have grown from I think it's around 12,000 in the first year of the program up to around 25,000 now and then on the side there I have growth in the count of practice sites that are part of this program and it is a growing program. This table is our analysis perspective payments as a percent of expected total cost of care and what are known as the HDP land category so this is the health care payment learning action network. This is a national framework to categorize different types of alternative payment models there's a reference slide at the end of this deck that explains that a little and gives you a link if you're not familiar with that but this is a way of looking at the payments within one care and understanding sort of where they fall on the continuum of value based payments which begin with fee for service no link to quality or value all the way up to global budgets or fully capitated payments and kind of what the steps are along the way so we like to look at the payments and sort of understand where they fit into that categorization. Okay and just to note the categories are not perfect to Vermont's arrangements but this is the best framework that we have to provide us with a national comparison and that we've used since the inception of the model I'll also note that there is not one way to design these models the goal is to link payments to quality and value but not all arrangements have to be categorized for in order to for this to work well so we're not necessarily saying everything has to move to an unreconciled fixed perspective payment there is a continuum which can be used and designed differently for different provider types on this table here we have average attribution so I don't think I need to get into this too much unless people have questions but the average attribution is the number it's not the number that's counted as of January 1 it's the average number of attributed lives over time that are used to set the budget maybe some context for that and to give you a sense of magnitude and so staff took the budget by 23 budgeted figures for expected total cost of care and fixed payments to calculate the total fixed payments as a percent of expected total cost of care and so we did it so the calculation here again is total fixed payments so unreconciled and unreconciled FPP plus CPR and you can see that Medicare is around 47% paid around 55% we have that broken out commercial overall is around a little over 1% and the total is around 30% which is that number I referenced earlier and that's been relatively stable so this year again we looked at FPP over time in the different payer program so those are the solid lines low Medicare overall FPP again has been relatively stable from 18 to 23 Medicaid which has the highest proportion of fixed perspective payments has also been relatively stable so the board has asked over time to set targets for achieving higher levels of fixed perspective payments noting that moving to this type of payment is one of the goals of moving toward value-based arrangement so we have done we have gone through a process on setting these targets and there's some challenges here because again the decisions around fixed perspective payments and operationalizing that do not sit unilaterally with one care it's a negotiation with their payers so we can't necessarily mandate a target and then hold one care to that because it's within partnership with their payer program so most recently one care submitted a report giving us the data on fixed perspective payments in July 22 and they they amended their goals their original goals that were set in May 22 and presented with their FY22 revised budget had set goals at 0.4% for Medicare 58.2% for Medicaid and commercial at 23.9% and the more recent reporting they amended the Medicare and commercial goals down to 0 and in the conversation on this that is to reflect the current state that we don't have additional arrangements for FY23 and one care didn't feel like they could set a goal that they felt was unattainable but we would still like to put a goal out there to strive for and the goals that we are recommending is closer to the original goals that were set which is working toward moving commercial to 24% in Medicaid to 55 there's something about the Medicare line there I'm not 100% clear why it was adjusted down because my understanding is they're already above that number but essentially the goal is to reflect the current commitment to unreconsiled CPR in the Medicaid program Medicare we're not recommending a goal because Medicare has indicated it will not convert to unreconsiled FPP in the current model so we expect that to remain status quo Medicaid again reflecting current commitment and then commercial we know for 23 that we don't expect new commercial offerings but payers have indicated in their presentations before this board even and possibly in rate review discussions or proceedings that this is something that is being explored so we think it is appropriate to set a goal so key takeaways again the payment models are consistent no major changes we're under in regards to FPP there we understand there's a satisfaction with and a commitment to unreconsiled Medicaid FPP Medicare has indicated it will not convert to unreconsiled FPP in the current model and commercial lags in providing any non-fee for service payment models within their risk-based contracts however up pairs have expressed willingness and progress in this area and one care similarly has expressed operational readiness and willingness as well for the CPR program the CPR program receives positive feedback and is expanding significant expansion could put pressure on hospitals that absorb the fee for service settlement we haven't explored this further but it is an area to look into exploring the expansion of the CPR program to hospital employed primary care and FQACs mentioned in the one care budget they are also exploring the CPR program moving to a percent of total cost of care as a way of achieving an increased percentage spent on primary care and linking primary care reimbursement with overall trends we are also curious about that but my understanding is that these aren't necessarily for the 23 budget they're looking ahead so the recommended approach to fixed perspective payment this year so the reason why we're setting these goals is because it's actually a requirement in the budget order and was set in guidance for 23 so per the budget order and the 23 industry guidance the Green Mountain Care Board staff recommend adopting goals for FPP which we would include in the FY24 guidance those are Medicaid at 55% commercial 24% the ACO as they have done must continue to report FPP data and progress toward the goals as specified in the ACO reporting manual and FY24 guidance and we want to state that the goals reflect an aspiration not a concrete plan the language that we used on this in the order I believe or the guidance was that the ACO shall use best efforts to meet or exceed the goals as modified here by the Green Mountain Care Board and I want to mention that this issue has been discussed as a a goal or strategy in the 2020 all-pair model implementation improvement plan and I want to note that in that improvement plan it was mentioned that MBP and one care identify clear milestones for including FPP in new contract model design and also you know we are hoping that the Medicare fixed payment model will align with the Medicaid but we know that that is not available at this time per discussions with Medicare and then the recommended approach on CPR is to share the one care Vermont CPR program evaluation which was mentioned in their budget submission and presentation this can be part of reporting manual requirements and this isn't a new evaluation it's an evaluation that they mentioned they're doing and we think it would be valuable to review we would also like to discuss and have them provide information on the impact of moving CPR to a percentage of total cost of care I think that this could be discussed potentially in the revised budget conversation but we can work out appropriate timing and we would also have them continue to provide the CPR standard reporting which is consistent with past years and the requirements are laid out in our reporting manual along to the next section population health quality and model of care this section of the budget itself is large including ACL quality population health model care community integration efforts I'm going to review major programmatic changes and sum up criteria so this slide not a substitute for reviewing the statutory criteria but it's meant to boil the criteria that are most applicable to review of the ACL model of care and population health program the let me quickly on the slide so what the board is required to do is to review and consider incentives and resources information and efforts so essentially payment changes that the model allows data that is collected and shared and efforts or tools that are used to support providers in implementing programs and moving toward value based models key criteria in the statute include strengthening primary care the effects on appropriate utilization and there's some specific call-outs here for integration with community based providers in the blueprint for health mental health substance use disorder for example and addressing social determinants of health and the impact of adverse childhood events and again of all the criteria we identified I think the seven that are down in the corner that are most relevant to this particular section and I want to know that the statute provides the board with considerable discretion in deciding whether these criteria are satisfied alright so this is a summary of the six programmatic changes that we identified through the budget review on the next several slides I'll go into more details on some of these as needed the first one here is the new population health payment model so this streamlines three payments into two the PHM based payments and PHM bonus payments second one is the sunset of care navigator for care coordination reporting this is going to end eminently here at the end of 2022 the use of this software however one care detailed the new requirements for care coordination payments which are tri-annual reporting validation audits and an annual meeting there is an updated clinical committee structure to align with the strategic plan and this committee structure is meant to inform the care model quality accountability metrics health equity data and analytics there's some updates to their focus areas which include food and security suicide prevention chronic disease and then the PHM accountability six measures which I will show you on a later slide updates their updates to their provider reports and data these include these are reports that are given to providers to provide them with information these include health disparity scorecards primary care panel report quarterly VVIS reporting that's the value based incentive on a new equivalent key performance indicators the benchmark report and then again the new analytics which was done through the new analytics platform and then they are some goals that they talk about in this section one of them is to demonstrate statistically significant improvement at the ASO level for all measures included in the PHM accountability policies as well as include a review of health equity in all efforts across the ACO I'm going to go into some detail about some of these so this slide or detail that I think will help you understand some of these this slide reviews the new population health management payment model as described by one care our understanding is that it supplies the same cash flow to providers in total potential of 17.6 million again they budgeted that about 80% of the eligible providers will be successful in earning the bonus dollars so that 15.3 is the base and the 2.3 is the potential bonus earnings eligible providers to receive these payments include hospitals and hospital primary care independent primary care practices FQHC designated agencies home health area agency on aging so again this sort of redistributes and provides funds to these providers to help them pay for for things that may not otherwise be covered for the structure of the clinical committees are important they are responsible for making decisions using data and expertise regarding one cares program so in the previous budget submission one care noted that one of their goals for FY 22 was to reevaluate the structure of their clinical committees and to seek opportunities to clarify their purpose and effectiveness in alignment with their strategic plan goals this is the updated chart describing one cares new clinical committee structure these are the population health management accountability measures for primary care so it includes these 6 measures potentially avoidable ED visits by those with 2 ED visits in the last 90 days follow up after hypertension diagnosis age 40 plus all payer annual wellness visits diabetes poor control child and adolescent well visits and developmental screening these are measures that are tied to bonus payments and I just wanted to know here that they did mention this goal of demonstrating a statistically significant improvement at the ASO level for all measures included in the population health management accountability policies and I'm actually going to talk about this again in the performance measurement section these are the key performance indicators that were discussed in their budget submission so in collaboration with the University of Vermont College of Medicine clinical research team one care has developed phase one KPI the second phase of these will be put in place for new health analytics platform launches in 2023 in this first phase the KPIs are for four key groups all of one care primary care practices HSA communities and hospitals KPIs currently in the first phase of development include these listed on the slide there is some we've been looking at all these different reports and outcomes measures and I'm going to talk about that a little bit more in the next section but there is a general overlap of these measures with the Medicare benchmarking report such as total spend primary care visits inpatient post-acute care ED visits and so we potentially do have a way of kind of verifying verifying results across different report types so that they feel more reliable or valid again this is a little more discussion on the reporting that one care produces to support providers so in 2022 one care started providing quarterly consultations to each of its HSAs on the areas of care coordination utilization quality and cost attendees vary between HSAs excuse me and it's still evolving in 23 typical attendees include hospitals FQHCs and other community organizations there are two new reports that give practice level insights and pair agnostic views that were not previously available this includes the primary care panel report which includes panel composition, total cost of care quality utilization as well as comparison to those of its peer group peer groups are provider or by provider or practice types such as FQHCs, naturopath independent primary care critical access or non-critical access the BIF reporting package includes multiple reports that were shared previously to providers but now in a more streamlined manner and one of our questions I think around these provider reports again we know that one care fielded a provider survey which I believe results are we do not have them at this time but I think we're going to be finalized shortly around this time of year and one of our questions here is you know here are the reports that are meant to facilitate and provide useful and actionable data to providers we're interested to understand how providers perceive these and are using them and you know their usefulness finally one care discussed some well probably not finally but next slide one care discussed their self-evaluation efforts which include care coordination evaluation the provider survey that I just mentioned I don't have on here the comprehensive payment reform evaluation but they do perform internal evaluation which we review or would like to review to better understand the impact and the outcomes and results of these programs there's some sort of high level summaries here but I'm not going to take the time to go through them the key takeaways on this section the total population health management expenditures are 29.9 million most of that is contractually obligated through their payer contract but about 10.3 million of it does fall in their entity level budget there is we've heard about there's been an evolution of the population health management payment model there has been phase out of some program support which was discussed in the hearing as programs that they provided start-up funds for and now they're being transitions to other ongoing support some have been phased out however the key thing here is that population health management investments those are small amounts that program support but the population health management investments are concentrated in the blueprint events shared savings and providing funding for that program the PMPM base and bonus payment and the CPR programs it's really their core population health management investments there's the new care coordination reporting after the sensitive care navigator and then again ongoing ACO self-evaluation so the recommended approach on the population health section is again to require one care to fund population health management and payment reform programs as detailed and to notify us of changes they also report to us on this in the revised budget this is consistent with past years the guidance we actually set sort of a benchmark in the guidance that VBIF or other pre-funded clinical quality incentives are funded at at least 2.4 million dollars we would like reporting of self-evaluation results to the Green Mountain Care Board and then that bullet the last dot there is the one that Sarah Kinsler talked about in a prior section this this is to require that the blueprint health payments are funded in the amount approved by the Green Mountain Care Board with under the Medicare ACO benchmark process and we are adding the addition of without passing risk associated with Medicare advanced shared savings payments on to the ACO network so this amount of risk in Medicare would drop to the one care entity level line if you adopt this recommendation and again the one care budget proposes a 5.2 percent increase in the flash and blueprint payments of which are recommendations consistent all right performance measurement and improvement Marissa do you want me to take this intro or do you want to do this intro I got it I think we consolidated right great yeah yeah it's fine in this section we're going to cover the history of the Green Mountain Care Board's approach to performance measurement and improvements and provide an overview of the FY22 budget order for the Medicare benchmarking report and a status update on the first report and end with the staff recommendations for an FY23 and FY24 approach so quick history of the regulatory approach here back to 2018 was the first time we included the condition that the health care savings must be greater than the operating expenses in 2020 we requested an evaluation of the effectiveness of population health program as well as an HSA variation performance dashboard in 21 we introduced more consistent reporting manual for this reporting and we again require the HSA variation performance dashboard those are posted on our website under those years for 2022 we move toward the benchmarking report recommendation so the previous HSA variation reports compared ACO practices to their peers within Vermont to look for variation the benchmarking report compares the ACO to its peers nationally specific to the Medicare program because that is what data is available for and the purpose is to support our data driven monitoring and oversight of one care while also supporting one care and identifying return on investment and areas of opportunity okay so the board and the public are asking through this process how do we measure success of one care what data do we use to measure success this slide is specific to quality and financial measure results that are produced by the ACO or the payers so external or third party evaluation will be addressed in the next section by Michelle DeGray so the suite of reports that we recommend the board rely on are on this slide so it includes quality and financial results of the annual payer contract scorecards which were reviewed on November 21st those are those are backward looking the performance benchmark report which was ordered by the board in last year's review as well as some one care measurements that they discuss the population health management framework measures and goals and the KPIs being developed by one care and the University of Vermont so I want to note when evaluating results which we're not doing today we're sort of recommending the approach but for even the highest performing ACO we would expect to see mixed results in areas of high and low performance but these measures will help guide our focus as regulators and should similarly guide one care's focus and investment there are other reports and evaluations mentioned in the one care submission or suggested by this board or I've discussed already we can collect other evaluations for Green Mountain Care Board review through the reporting requirements so we can ask them for you know CPR program evaluation care coordination evaluation of provider survey as mentioned but if we're trying to select sort of a suite of reports to rely on these are the ones that we recommend okay so on this slide are the requirements of the performance benchmarking report that was ordered in FY22 this is directly from the budget order the staff have worked closely with one care all year as they developed this report which we received in late October reviewing and approving vendor selection and report development the first report was just submitted and at this time our assessment is that they are in compliance with the FY22 order however we have not had access directly to the vendor analyst and we continue to have concerns about the final methodology so if you break this down like A is around the methodology we still have some questions there however they have provided a report to us and explained it and the methodology additionally we need to understand how one care plans to use the report to satisfy B there which is how you're going to take your results and turn them into an action plan specifically how they use the results and identification of best practices from high performers to create an action plan we need to satisfy A and B before we are confident we can use the report for regulatory purposes are they doing these things as stated at the beginning of this presentation this approach was envisioned as a multi-year process when it was recommended so we did originally supposed to get the report in July we extended it to October so we are somewhat delayed in being able to review the report but we did always envision it as a multi-year approach and just as a reminder again some board members are new and as I mentioned before this started last spring with a review of core competencies of high performing ACOs which led to the recommendation to implement performance benchmarking which led to the development of the performance benchmarking report for one care and the next step would be target setting and requirements for performance improvement plans so I think it's a lot to try and absorb this report in this presentation but I'm going to just sum up our methodological concerns in two slides and we're going to return to interpretation of results at a later date so the report has from years 2019 to 2021 the benchmark cohort consists of 20 ACOs making up about 700,000 lives the cohort criteria includes ACOs with a two-sided risk model high-revenue ACOs 20 to 80% of attributed beneficiaries live in urban zip codes 40% or greater attributing specialists with patient panels and less than 15% of attributed beneficiaries are duly enrolled for Medicaid so this started with the full Medicare ACO nationally which is 513 ACOs I believe and applying this criteria brought us down to 20 ACOs and then utilization and cost metrics were adjusted to account for risk scores and unit cost adjustment the significant limitation is in the call-out box there and that one care in the contractor chose to identify a 90th percentile cohort rather than evaluating highest performers for each measure so additionally the small size of the cohort means that 90 percentiles is two ACOs to sort of limit the ability to identify best practices essentially they took the highest performing two ACOs in the cohort for cost measures and then compared one care to their performance for the 90th percentile but then they've also supplied a median or 50th percentile which compares one care to the average one care did include some high-level interpretation in the full report which is posted on the website and again that's just an example of the measures and the way the report looks people should you know I encourage people to take a look at that on the website but at this point we're not ready to draw conclusions from the first benchmarking report due to remaining methodological issues but we'd like to work these out in time for the budget guidance in the spring and then sort of in plain language seeking to answer certain questions from this data how does one care compare to the top performers in each category or metric in which categories does one care excel and in which categories does one care perform poorly in which categories metrics are one care results low cost or high quality so where's their best performance and in which categories metrics are one care results high cost or low quality the worst performance so essentially one of the greatest areas of opportunity for one care to make population health investments in which one care Vermont investments are providing a return I think I've covered this essentially showing this is this is a summary of the requirements and you know here's where we're at and we're still working through this still working through this process I want to say that preliminary performance targets were included in section 8 of the FY23 budget so kind of art thinking of how we would use this report was included in this year's guidance but we want to refine that for 24 and again I think we've probably covered this great okay so the key takeaways on performance measurement and improvement existing performance measurement does not satisfy all green mount care boards request for a certain assessment so this when I say green mount care board request I mean things that have been in the budget order or things that have been discussed we wanted to sort of sum that up board members and the public are looking for one care Vermont patient and population outcomes at the ACO level compared to high performance targets and trends we are looking for a way of calculating a return on investment on one care investments including population health programs and administrative expenses and a relationship between one care Vermont programs and investments and improved outcomes such as a third point a definitive causal relationship on the ACO as an intervention may not be attainable because of the complexity of the intervention but that doesn't mean we can't do robust analyses that will give us important information about one care's impact so one care makes speculative claims that their interventions cause the specific outcome but then they clarify that their goal is not to tie direct causation of one care activity to the particular outcome of interest we urge one care to be more cautious about inferring causation without providing high quality data to back up their claim but we do have some recommendations about analyses for the coming year which Michelle will cover and again this has been an ongoing conversation is included in the healthcare advocate comment as well. So finally on this section the recommended approach is to build on the FY22 budget order by requiring improvements to benchmarking reports and this includes identifying best performers and best practices clarifying required methodology for the comparison to best performers we are would like to discuss per measure comparison rather than identifying individual high performing ACOs and comparing across measures we would like to discuss the capability to provide ROI calculation for areas of improvement and we are interested in seeing a larger and more transparent comparison cohort and we recommend requiring one care to meet specific performance targets in FY24 guidance and to indicate how benchmarking report results drive PHM spending decisions I'm going to turn it over to Michelle to discuss results to date. Thanks Marissa just confirming you guys can hear me okay? Yes okay as Marissa said I'm going to talk about three things today federal evaluation of the all pair model by NORC all pair model scale targets and a really quick overview of 2021 settlement which we reviewed on November 21st and Sarah and I have a duplicate slide so we can probably skip pretty quickly and I'll also note I'm here to bring it home so we're almost done Marissa you can go to the next slide we're going to start with an overview of the NORC federal evaluation so NORC is contracted by CMMI to evaluate the model this is a requirement of all federal models the focus of the evaluation is to assess the model's impact on the Medicare program and Vermont Medicare beneficiaries so while there is correlation to ACO performance there is not an evaluation of the ACO's performance just want to make that clear Marissa you can go to the next slide just linking the reports here for those interested in doing a deeper dive each report includes the full evaluation report which is lengthy findings out of glance and technical appendices those are all posted on our website and they are linked here for your convenience next slide so this is a repeat slide from last year but I wanted to sort of highlight it so this is the first evaluation report so that was performance years one and two so 2018 and 2019 these are the key findings that staff presented on during last year's budget presentation and some of these you'll see carry over into the second evaluation which I'll talk about next so from the first year we did see some positive takeaways like overall reductions in Medicare spending and utilization for the entire Vermont Medicare population versus the comparison group we saw improved cohesion around shared goals and collaboration across the state and realized some spillover effects into the full population beyond your Medicare beneficiaries we also saw some opportunities namely the lack of widespread understanding of the model and the recognition that transformation is going to require a more robust transition to value based payment and investment Marissa go to the next slide so this is from the second evaluation report so now we're looking at performance years one through three so through 2020 so highlighting some high level findings here of that second report but also want to be fully transparent and recognizing that staff received this report about three business days ago so we have not had the opportunity to do a full deep dive but plan to do so as soon as possible just being honest in the second evaluation report which now includes performance year three 2020 we saw continued reductions in Medicare spending and utilization for the entire Vermont Medicare population and ACO attributed population versus the comparison group and continued to realize spillover effects into that full population not surprisingly COVID response was the priority for providers and and stated so in 2020 and 2021 so it's going to carry over likely into next year's evaluation APM and ACO infrastructure and payment models really supported that public health emergency response which we've heard about in the past the UVM cyber attack was noted in this evaluation report which caused major challenges and is a factor for analysis and it's also noted that continued lack of widespread understanding of the model so kind of a carryover from from the first evaluation more say you can go to the next slide moving into all pair model scale Sarah also touched on this earlier so just to note that commercial programs are typically finalized in the spring of the program year sorry someone's not muted so commercial programs are typically finalized in the spring of the performance year Medicare and Medicaid must be executed by the 31st so by the end of this month so we'll have that information by year's end so what I'll show you has some of that information but we'll wait until the revised budget to get the final results for some of that there's minimal concern though that the Medicare and Medicaid programs would fail to be scale target qualifying so typically not worried about that aspect again just want to note here that scale targets have been waived but reporting and assessing the programs against that agreement criteria is still a requirement through the expansion period so we'll continue to report if they can go the next time so here's a glance at scale performance over time by pair contract a few notes here so we use prospective attribution obtained directly from Medicare and Medicaid for those first two rows so these numbers differ a little bit from what is in the initial budget proposal from one care that makes sense and it's okay and we know that to highlight some takeaways we're seeing growth in the Medicare and Medicaid space both in the traditional and expanded cohort and Medicaid and a slight reduction in commercial across all programs Marissa you can go to the next one Sarah mentioned I wanted to touch a little bit on Medicare advantage penetration so something we want to continue to highlight which you can see has been trending up since the beginning of the model for the current year which is 2022 and that's only through August that's the data that's available currently or should I pulled it three days ago so I hope it's still accurate we're seeing nearly 27.3 so nearly 30% of Medicare enrollees opting for these types of plans it is very likely that we will see a similar increase in 2023 enrollment the impact here is just thinking overall about how the shift out of the traditional Medicare population impacts PMPM because the people that are left in traditional Medicare typically have a higher morbidity or risk score and therefore would have higher PMPM Marissa you can go to the next slide it's freezing a little on my end hopefully it'll catch up I can just I can talk maybe it'll catch up yeah there's a little fitting wheel saying that our time's almost up hopefully it's gonna catch up or we'll reload it okay this slide you've actually already seen Sarah presented it anyway so I'll just talk about it briefly and then hopefully it catches up so it's just a quick recap of the November 21st presentation it's just a settlement result so approximately 8.2 million in shared savings earned and eligible for distribution which again excludes the shared savings advance in the Medicare program which Sarah talked about so I will not repeat it and I'll wait for Marissa to try to reshare reloading it and now we'll be on slide 103 if that's helpful still getting a spinning wheel so I'm gonna stop it and try another way I apologize Sarah do you want to try taking it in case this doesn't load for board members who are here you might recall that I'm always the one who breaks it so just as happened before not the first time why don't we do this why don't we take a 5-minute break so people see you have a minute and we'll come back at 305 and we'll see how we're doing okay so we're adjourned for 5 minutes to 305 thank you hey we are back it looks like it's working so take it away all right thank you and thanks for the patience with troubleshooting so reviewing quickly again the 2021 results that we talked about on November 21st we saw mixed results here so that's sort of irrespective of scoring methodology used to look at the actual performance we saw some mixed results in the final quality metrics some increases and some decreases and all of the programs that present it and I also just want to point out that while we do now have four points in time comparability is going to continue to be a challenge given several factors first being the difference in the Medicare program quality framework in 2018 so essentially we have three points of time in the Medicare program where all of the same metrics were used two of those having been reverted to paper reporting due to the public health emergency we have introduction of Medicaid expanded attribution and of course COVID public health emergency which led to a change in paper reporting versus paper performance in a lot of the programs additionally just another point I always like to remind folks of is that we have to consider scale growth in each program over time and the potential impacts that growth might have on payer program results Marissa you can go to the next one the takeaways so there it is through a scale enforcement has been waived but we'll continue to report and assess programs for compliance also just again another note that scale achievement is not necessarily a reflection of ACO performance but it is reflecting many factors including care and insurance market patterns continued growth in that Medicare space and again we expect to see that continue payer performance continues to vary in both savings earned and in quality performance and then as Marissa mentioned earlier it's really challenging to identify causal results due to complexities of ACO programming in the overall state health care environment the continuing impacts of COVID-19 and national trends Marissa next slide so with that the recommended approach here staff recommend requiring one care to complete an ROI analysis comparing their administrative expenses to health care savings including an estimate of cost avoidance and the value of improved health this is consistent with past budget orders which have required that this be done over the duration of the AAPM agreement of which the original term ends this December 31st 2022 so we're asking one care to conduct their five-year analysis of the original agreement term in this recommendation although already required by rule the GMCB staff want to ensure access to data required to conduct any analysis but the board staff want to do at sort of a staff level also so just flagging that we're calling out rule 5501 here just to make sure that one care complies with any and all data request to aid in that analysis and with that I'll turn it back over to Marissa that concludes our staff slides and review preliminary recommendations on the budget so I am just a reminder we have several deliberative sessions and a vote by the end of the year and I will turn it over to you chair Dr. for board discussion and questions thank you all very much are there any board questions or comment chair this is this is Tom Walsh I have a couple please go ahead thank you first thank you to the staff is just an incredible amount of information that you've provided it's going to take at least me it's going to take a few days to digest a handful of questions they're basically broad strokes I just want to make sure that I'm understanding things well and if I ask something and somebody doesn't have the answer right away that's completely fine this is just to help me understand things better so I want to start I wrote down some slide numbers as we went and if it helps orient people but I thought it was really helpful to go through the breakdown on slide 14 with the with the diagram the total amount of healthcare spending on Vermonters from that diagram was $6.5 billion $6.4 which is a lot but about $5 of that is patients who have been attributed to one care Vermont if I've read if I've paid attention well and so by the time we get all the way out there to the left we're talking about $1.5 billion as opposed to $6.5 billion is that do I have that correct yes okay thank you and so then if I followed it gets broken down further into the one care broadly but then one care as an entity that was a few a few slides later around slide 29 through 39 in that section I think the point that I took away from it and I want to just double check the proportion of funds that focus specifically on the one care entity ends up being in the $25 million range you want me to clarify or speak to that yes so the $25 million is the entity level amount so these are funds that are not obligated through the payer contracts that is mostly the revenues and expenses for administrative costs and the operations of one care so the 15.2 and a portion about $10 million is in the population health management program the total population health management spending is $29.9 million but most of that is contractually obligated through payer contracts it still represents investments in population health but only about $10 million of that remains sort of more at the discretion of one care okay that helps thank you this flow is complicated so please bear with me while I try to figure it out the $25 million the entity level does that include dollars for data analytics the dollars for data analytics that are included in there administrative costs contracted services software yes is in that $15 million and how about the blueprint and SASH funds the blueprint for SASH funds is in the total accountability population health management budget so that is contractually obligated as part of the $29 million in population health investments one care administers those payments but they pay them out according to the budget order and the agreement with Medicare so we've had some public comments suggesting that that funding could just simply be removed from one care and put in AHS but that's that wouldn't be a simple thing to do and if it were done that money that money is going to providers to provide care it's not going to support one care operations is that correct the mechanism by which those Medicare investments are paid to providers and the blueprint so I think it's fair to say that one care is the fiduciary agent of the dollars they they take the Medicare dollars and distribute them to the blueprint removing that from removing that fiduciary responsibility from one care would not alter the entity specific $25 million that we've come to understand correct it is not included in the $25 million Marissa and Tom if I might add we the state of Vermont has worked with Medicare to discuss other potential ways of bringing that Medicare funding for the blueprint PCMH, CHT payments as well as the SAASH program into Vermont and we have not been able to find another mechanism that's workable for Medicare so while we recognize that this that the advanced shared savings savings mechanism is somewhat complicated it's kind of the mechanism that we got to continue to have Medicare invest in those foundational programs that have been positively evaluated so that's very helpful because that sounds like if we were to try to do it a different way Medicare may just simply not pay us we need we need a different contractual relationship if we precisely like if we want if we want to be able to bring these Medicare dollars into Vermont this is the way that we that we can do it for now like we could get a new a new arrangement but that would be that's going to take time and needs a willing partnership with Medicare okay that helps me a lot so thanks for I see Robin shaking her head like she knows this but it's I'm getting up to speed so I want to ask some questions about the risk model and it seems to me this is my questions start on slide 57 it might help to go there if we can without breaking the internet nice so here it looks like the vast majority of risk with these contracts is held by the provider the providers and that risk has grown over the life of the ACO entity meanwhile one cares assets have grown am I interpreting this table correctly yes so there's there's probably some nuances here which may be at one point we would want one cared to clarify but from the information that we have there was a board order 3.9 million of reserves in 2019 those assets grew to 5.6 in 2020 our understanding from the audited financials from 21 is that they have grown further however I do not believe that those have necessarily been set aside specifically as reserves I would want one care to speak to those but that's what we see in the audited financials in 2022 projections and 23 information they have that level remaining at the 2020 level and then yes so I'm going to leave it at that and would probably defer to one care for further clarification but there they have grown somewhat since the board ordered they have grown since the board ordered reserves I think I can and I get I understand causality is difficult and assessing the relationship between changing numbers is difficult their assets have grown or at worst stayed the same while their risk with these contracts has declined the risk bearing amount that one care has held declined while the risk to providers has grown by roughly a 10% swap since 2019 is that correct you want to take this therapy sure that's correct Tom I think we all recognize the pandemic has brought extraordinary circumstances it's not so I think it's not surprising and is appropriate that there would be some decrease to risk during kind of the roughest period of the pandemic and I guess late pandemic early post pandemic after effects the challenging times that we've seen our healthcare providers especially they see as risk bearing entities in so it makes a lot of sense to me that I think we're down in the 2020 post COVID budget and 21 and 22 I think we're hurting to see that kind of coming back up to near pre COVID levels in 23 so while you know risk took a significant dip I wouldn't I wouldn't look as much at the total risk level I think in terms of one care risk you're absolutely right as I mentioned when we talked through this slide one of the one care taking on risk for providers in earlier years in particular had been as a way to help providers join a new payer program so in particular it's been used as a way to help providers join the Medicare ACL initiative if they're not quite up to taking on kind of the full risk amount that would be delegated to them based on one cares methodology and their attribution etc etc in that first year so that it's been what they have used the one care held risk for as you'll know staffer recommend recommending that one care actually take on a significant increase in risk in 23 in our recommendations for them to take on the risk associated with the blueprint and that advanced shared savings methodology so you are seeing an increase in net assets and equity here but we're recommending a significant increase over that 24k that's helpful and a little just some more context that hasn't been provided here many high performing ACOs across the country assume 100% of the downside risk and many newer ACOs use that as a feature of their business model they are so confident that they'll be able to achieve these savings and hit the quality marks that they assume 100% of the risk the providers have none they want to stick a pin in that could we go to slide 73 please that's probably not the one I wanted I'm interested I'm trying to follow the population health payments the provider reporting some of those things as we've received more evidence it seems that some of those responsibilities may be shifting to the UVM health network and I don't yet understand what that means for one cares budget does that money leave one care do they still do they still need as much in dues from participating hospitals what does that mean from a budget standpoint like the sunset of the care navigator for example and how do these things affect the budget so the overall effect that one care testifies to is that it is budget neutral that the buckets of money that pay for these things are transitioning from you know in-house analytics and software to contracted services like I think Matt mentioned we did ask them for more detail about those specific contracts and pieces of software of which some of it is deemed confidential so we did not provide that here I do think the movement within the budget we may need to discuss in a way that we can look at the confidential information but then I also think that some of this discussion will be in part of the monitoring investigation that Russ discussed okay that makes sense so I'll hold off on more until we have those meetings the goals here on this slide demonstrate statistically significant improvement for all measures I think it's on the next slide or maybe slide 78 it lists the measures right so if I'm to under so child and adolescent well visits as a measure that sounds like it will be the count of how many occur if 100 well visits occurred in 2002 how many occur in 2023 or if we went from one well visit in year one to two visits in year two we could if we were promoting ourselves claim a 100% improvement these are counts is that correct I think I deferred discussion about how the particular measures work to one care themselves or if Michelle or someone else is more familiar with these measures wants to answer that but I would rather not that I understand I'm not I'm not trying to give anybody a hard time I'm trying to understand what this this means it it seems like for follow up after hypertension diagnosis that would be a yes or a no right and so then I'm trying to think through what would be statistically significant improvement and while I like the goals and I like the words used these seem like a very low bar so I'd be happy to be proven wrong but you know that I think I think the reason for the recommendation or why we have sort of a suite of reports is that we're trying to collect information that one care already collects and measures and see if that is sufficient to meet your needs and if you're not then that's part of the discussion but this was one identified area that we could look at in a you know a suite of reports yep and there's some overlap with Medicare reports Medicare reports several of these already without needing any analysis from one care or UVM health network is that correct this would be sorry Marissa hi Tom this would be for the full ACL population not specific to just Medicare attributed live okay okay so that's kind of so okay so that's the full population so and yes there's a lot of overlap here with all pair measures in total and payers specific all pair model measurement or sorry pair specific contract measurement not all pair model measurement so there is a significant amount of overlap with these measures okay okay I don't need to ask that on slide 82 there's talk of phasing out the blueprint and CPR what helped me understand what that means here and what that would mean to the budget sorry yeah that might be confusing that is a confusing bullet point so thank you for pointing that out there's a phase out of some program support which I think you can see on one of Matt slides that some of the smaller amounts in Dulce or some of these other programs I have to let you remember what they are though those are being phased out one care to that what this means is that the phm investments are actually concentrated in the blueprint the PMPM base and bonus payments in the CPR programs those are their core investments there are some other investments that are smaller some of which are being phased out I see now that that particular bullet point there on the slide is misleading so might correct that just yeah when you have it the way you think it's best let me know so that I under I can understand um takeaway is that those are the core program population health investments the blueprint the PMPM home payment and the CPR that that comprises the bulk of the population health management investment okay um could we go to slide 88 please um and so here would you help me understand the limitation of choosing the 90th percentile as a comparison group does that mean they're comparing themselves to the top 10% or am I missing this and I do understand that that choice substantially limits the comparison group I get what it does to the sample size but um help me understand any other limitations please okay so let me let me try and if someone else can can jump in if I don't have it so the way they constructed the report of the 20 ACO they identified the top 90th percentile which is two ACOs on two measures I don't think I have it on the slide but it's total cost of care I think so basically the highest performing ACOs on cost and they said these are the highest performing ACOs in the cohort and then each individual measure they compared one care's performance to those two ACOs so that when we saw that that was not our understanding of how this report was going to be performed our understanding is that we were going to get the top performers by each category um and then understand who's performing best on each measure so we are still working out that that and if it can be performed the other way we did not feel like we had all of our questions satisfied on why this methodological choice was made right well good it's a good it's a good catch so thank you for getting it because it's unlikely that the top the same two ACOs are the top performers across every measure correct so that's a very important thing to fix yeah we agree completely Tom that that was something that we noticed as well uh one really what we were looking for in requiring you know seeing the 90th percentiles we want to get a sense for each of the measures in the report what is what's the ceiling what's a reasonable ceiling to expect um so you know rather than just looking at kind of two ACOs that are high performing on cost we're looking for a measure by measure um understanding of like what is high really high performance look like please keep pushing it's good catch on your part and um please um slide 103 please this is for the the quality scores um and I just want to make sure that I understand um I think it's very clear the words are here but when we start showing quality scores and seeing 100 percent that looks like high quality but by reading the words in addition to the numbers most of these 100 percent mean they submitted 100 percent of the data not that they achieved any benchmark and when there are opportunities to look at benchmarks those numbers are in the 85 to 90 95 percent range in 2018 and 2019 but the only recent one we have is the one I cited in our last meeting on this topic and that's with the Medicaid group and there the score is less than 70 percent so I want to make sure that I understand that and I want to make sure that anybody listening understands that um we did calculate the Medicare score in all years outside of like what it would have been if it weren't reporting only and that was presented on November 21st all in there um but per their this is per like what is in their contract this is the result that one care earned so that's what we're presenting here but yes you're correct we did calculate it outside of that parameter um and then slide 105 last thing how many times has one care been asked to provide this ROI analysis it's been in the budget order since 2019 however it is also written over the duration of the agreement so you could interpret it to mean what at the at the conclusion of the agreement please provide this um but it has been asked and been in the budget order since since 2018 18 19 20 21 20 four or five times um okay I would like to so sorry Tom I would like to clarify on that point we haven't um we have said that our expectation is that over the you know five years of that original agreement um that that condition would be met but we haven't actually asked for an analysis so by you know we've looked into whether there might be a compliance issue on this condition we don't believe that there is a compliance issue on this condition so I think you know Russ if you have anything to add to that and you want to jump in please feel free to but um but it but you know if there's a compliance issue we can remediate a compliance issue but I think in this case um the the ask has not been you know provide us this analysis this year uh now it will be um so you know we're we're saying you know the original five year term of the agreement uh is concluding and we would like to um we would like to to see an analysis and we want to make sure additionally that we have a chance to um discuss the potential methodology or proposed methodology for that analysis uh and for the board to kind of have a have abided that apple so um so that's something that you know staff are proposing in our recommended approach to say okay it's been in the original term of the agreement is up um let's let's better understand how you would like to do this uh and and discuss the specifics and then let's get some initial analysis. Great thank you for setting me straight I had misinterpreted that so that that's exactly why I asked the questions um and I know being asked questions about your work for anybody that's it's stressful and having that happen in public is really stressful and so just thank you for for putting up with me um and doing this in public it it's the way we have to the way we have to um so I'm sorry that it's stressful but thank you very much for the work you've done I know you've put in a lot of hours and thank you for answering my um extra questions our pleasure thank you okay um Dr. Merman do you have any questions or comments? Sure um that I really appreciate a lot of I mean comments and questions and my god the amount of work you've done the team on putting this together and digesting it and presenting it is amazing I know I've gone through the binder but you guys have gone beyond that so thank you so much um I guess I have a few comments and a few questions and one of them I think is just between the last several hearings trying to come to understanding what what to expect one care can do and I think that's something I've been struggling with and I think there's a lot of ideas about one care what one care can do um and what one care is capable of doing and I think you know the I guess that a lot of the things that were discussed in their presentation I've been trying to understand one of them is cost um and I think that I've come to the conclusion at least at this point that um in the current model that we have that it's not going to be a profound change in cost that might move it a percent or two this way but and that most of the cost reduction strategies are going to be through uh long-term improvements in quality and through the gains from care coordination activities and reducing um um possibly preventable uh hospitalizations and ed visits is that sound kind of reasonable those the main cost reducing activities that they have that sound accurate to me okay and then quality um again um I think that from my understanding uh that the major quality initiatives are uh tracking these various metrics that we've been tracking and uh and reporting on them which um which it's uh providing data to providers to figure out if they are providing good quality care um again the care coordination component and I think I think that's the majority of the quality stuff is is there something I'm I'm missing that they major components that they do that provides potential improvements in quality of care um I mean that sounds right to they do have um and are required to have quality improvement plan I forget the actual term is that they use that is in the in the rule um but um but yes they are required to report on progress uh on that plan I think member member Walsh was bringing up the quality improvement questions and the more recent hearing that I think I think maybe maybe we could try figure out if we can get some insight into what those plans look like it sounded it was unclear to me whether how they're defined it was there was a lot of conversation on that but I don't know where we finally settled um one area that I think that seems to come up as a as a real benefit of one care from uh primary care providers is the cpr payments and the sustainability of that provided for them through the course especially the pandemic and going forward so I think that's that's one component of one care that I don't think I understood prior to these hearings that it seems quite impactful to to the health care system and then also the funds flow of care coordination dollars um seems seems uh impactful but but it also doesn't seem necessarily unique to the one care structure that this could go through potentially some future agreements with Medicare or different directions but that would be Medicare dollars um and then the last thing that they in the end of the presentation that I think one care sort of seemed to define itself by as being a data analytics organization and providing um high quality data analytics to provider organizations to help improve their practices and so I think that seemed to be a focus of where one care um is is going so that was just sort of I just want to sort of summarize my my sort of understanding of the organization and and here if if anybody has any thoughts if that seems like a a reasonable summary of what their kind of core capabilities and services are anything that sounds wrong but again I don't think these are all directed at me so yeah well you're the one answering which is wonderful but I don't thank you board members or other staff please please so I agree with I would like to continue to um understand this uh data analytics contract with the UVM health network and and I know um this is an area that the healthcare advocate has concerns and I think I voiced concerns recently and try to understand the relationship between one care and UVM and the data contract um and so I appreciate um for us the efforts to maybe move that into a separate um investigation um I'm covered a lot of what I was interested so I don't want to go on too long I guess one of the one of the things that I'm trying I'm struggling with and all the benchmark data and the NORC data is what and and this gets into sort of the complex issues of causality and correlation but I think I feel like there could be more um clarity here is is is trying to understand what the impact of one care is and and and how that relates to say patients who are attributed to one care or not one care or patients who are attributed to one care over time in these um quality metrics that we've been following and and I don't think I've felt like I've had great understanding and insight into um what we think is one care and I think also we talk about the spillover effect is it's things spilling to one care or spilling from one care Vermont has sort of unique health care delivery structures um and so I I don't know if I I don't think I've been satisfied yet and trying to understand what is the one care effect and how we can and and how we can understand what their impact is into the delivery systems of health care and what is just Vermont health care because like we are we're a really cost effective medic Medicare state and and we do things a lot differently here as a population than many other states so um again not really a question more than an observation I think the only other um question that I think I would like to ask at this time is a question on slide 57 we don't have to go to the slide but this is one cares assets um and this 5.7 million dollars in assets do we have any idea where these assets are held like how is this are they held by one care or are they held by their parent organization great question um board member merman and one that I would have to defer to our finance team uh if they have the answer or we can get back to you next week um when you reconvene and deliberate on this but it may be that Matt or Flora or Sarah Lindberg can answer that off the top of their head Matt here I don't know offhand so I'm happy to get back to you with that though great thank you so much yeah I think that's all I have for now thank you so much this has been incredible amount of work to go through this and I really appreciate the presentation of clarity this lunch do you have any questions or comments thanks um I have a couple first of all of course thank you to our staff as always you guys have done an amazing terrific job um marshaling all of this data and information and the reams of information that you have to process is incredible so thank you um I had a question about the decline in the Medicare uh total cost of care dollars and I was curious if we know what's driving that if that's related to the Medicare Advantage penetration or something else and if we're not sure obviously please uh follow up but later can you direct us to a slide no I cannot I didn't write down the slide number I am uh it was in I think one of Matt's slides okay I can see if I can find it at the top of my head I I couldn't answer um you know accurately about the drivers for that not have something to look at so maybe that's something that we can touch back on next week totally uh or the finance team wants to jump in I think let's to just take it you know later no worries I was just curious about that and we may not be able to follow that that ball but with the Medicare Advantage penetration growing um it's just interesting to see how that flows through to the financials um I had then I had a couple of comments that um actually came out of our meeting in Rutland uh but actually dovetail I think nicely with some of Dave's comments I was I thought it was interesting um a couple of different things from the Rutland presentation that really to me potentially explain some of the spillover effect that we see in the evaluations um specifically when we when we were talking to the community health team they call it the accountable community for health the blueprint community health team uh they were talking about the implementation of the Medicaid expanded ACO program in their community which is done through the blueprint community health team and how when they are doing outreach to those patients without primary care providers they don't just limit it to ACO-attributed folks they basically do it with anyone and so um I just thought that was interesting because one of the areas that I think we've discussed uh for many years is to Dave's point in a state where we've had a long history of the blueprint for health the medical homes and the community health teams and where we have statutorily required that the ACO not duplicate but instead use those structures for implementation of any of their programs I think it can be quite difficult to disentangle what's the blueprint versus what's one care and that was just kind of an interesting example and to me um maybe if it is widespread and more than just this HSA explains why we see this spillover more broadly because from the community perspective they may just be implementing it across the board regardless of attribution at which point you would see any impacts in the population more generally so that was just an anecdote I wanted to share and then to your COVID-19 slide again a story from Rutland's that was interesting to that really highlighted starkly for me not being a clinician uh some of the impacts from COVID and the difficulty kind of regrouping um was that the place that I visited was the Westridge Center which is a substance abuse disorder treatment center and they prior to the pandemic ran I think they said over 60 different like in person group um groups for their 400 patients and so they are obviously a very high touch organization that completely went away during COVID and they haven't been able to reestablish those 60 groups so what that kind of highlighted for me that maybe some of what we're seeing in the 2021 quality and other um sort of issues is that we know from our hearings during the pandemic that basically healthcare reform activities were put on the back burner understandably because people were dealing with the pandemic and so I don't think there's an answer to this question but I think it'll be interesting to see how quickly uh that comes back uh because the the ACO since the implementation of the programs is to Dave's point providers is going to be there their success is very much tied to when the delivery system is sort of recovered enough from the pandemic to be able to reconvene their healthcare reform and delivery system reform activities so those were just a since I know most of you were working hard on this presentation it was just a couple of anecdotal examples that I thought kind of highlighted some of the challenges that we see with some of the data and I wanted to share those with you um and that is really actually related to that the blueprint issue I was wondering if it might make sense when we get the care coordination evaluation to share that with the blueprint for health since the implementation of care coordination goes through the blueprint for health community health teams just to see if they had any comments or thoughts on that so I was going to suggest that and also if you I wanted to ask if you had shared um any of the recommendations that touch more directly to the blueprint programs with AHS in case they had any thoughts we did talk with Edan back as the director of healthcare reform about the overall blueprint CHT trend for that one care is proposed for this year we also spoke with her about the our recommendation related to the risk related to the advanced health savings dollars and I believe also the Medicaid FPP target was discussed with Diva great thank you I just wanted to make sure those communication loops were flowing yeah that's all I had thank you very much Miss Holmes thank you I just have one comment actually and one quick question I think my comment is broadly around evaluation and I think you know we've had public comment we've had board concerns about how we better evaluate the impact of one care Vermont on Vermonters and we get lots of data we have reports but sometimes it's hard to navigate all these different measures and try and attribute causality so I just wanted to throw out there to the staff that perhaps we might need to do our own internal assessment where we compare the costs and the health outcomes for a continuously enrolled ACO attributed population with an otherwise matched sample you know a match sample of otherwise similar patients who have never been enrolled in the ACO and look at them over time and I just so I just want to throw out there that that may be something that we explore doing in the coming months and we may need some data from one care to do that but we also have some of our own you know databases that would allow us to do such an analysis I want to throw out there that I think I'd like to see if that's something feasible and then my other my question really was the recommendation by staff to request one care Vermont to submit the methodological approach to conducting that ROI analysis comparing their admin expenses to the health care savings and I just wondered if the staff had considered or would consider the feasibility of thinking about providing some sort of framework framework or guardrails or expectations for what that methodology looks like so that we can ensure that we're getting what we want and so my guess I would just maybe we can think a little bit harder in the next week I'll do that and maybe others can as well what would we expect you know what are some of the expectations we might have for that methodology so that when if that's something that the board approves when one care submits it in April it's really truly what we want and what we're expecting and what we need so that's just a question which you can we can talk about next week if that's better or if somebody has a thought on that today that'd be great next week's great Yeah I think you're all unmuting and waiting to see if someone else is going to jump in the challenge of having a large team I think that that's something that we should definitely discuss internally as staff and with you Board Member Holmes we would certainly want to bring in staff from our data team and make sure that our data team was able to kind of help us help us think through the options. I think that there are also potential opportunities to work with the blueprint for help on this for Board Member Lunges earlier earlier comment and to see whether we could collaborate with them since it is going to be challenging you know there's potential for it to be really challenging to disentangle the blueprint and one care interventions among others. That's all I have Chair Foster thank you and thank you team again a lot of work a lot of slides a lot of analysis and very much appreciated I believe Dr. Merman had one other additional question if you'd like to go doctor go ahead Oh thanks so much you know just one quick comment I think Jessica I really like the idea of that matched control study I do think one thing to consider maybe is that the penetration of one care so high that finding appropriate match controls might be challenging just but I really like I think it's the kind of stuff I think we need to do but my question was actually on one quick question on executive and ACO compensation that came up is I was reviewing the rules and our rules as an ACO structure it's executive compensation to achieve specific and measurable goals that support the ACO's effort to reduce cost growth or improve the quality and overall care of enrollees or both and so I think one thing that I would like to see if we could obtain this from one care is those specific and measurable goals that the slide that was presented on executive compensation has really good conceptual framework I believe for the compensation but I would think that if there I would think there's probably specific and measurable components to that that would be very helpful to see just to confirm that the compensation is in line with those efforts to reduce cost and improve quality so I guess my question in that is could we request that I think that was part of our next step in informing conclusion on that on meeting that particular requirement thanks just had a couple on slide 88 about the I don't think you need to go to it but the issue with the methodology when did we learn about the methodology being different than we had anticipated and had we communicated our expectation that it should be top performers by each category that's a good question I would have to look and see specifically which meeting we learned that I do think it was earlier this fall and we've read our language requirements multiple times it did come a bit as a surprise to us but also it was you know it's challenging to get the specifications just right in the language so we've had an iterative process with them but I would say that we didn't learn this till later in the process but I don't want to say exactly when because I don't have my meeting notes in front of me I don't know if this is feasible or appropriate but if it is would it be possible to participate in the methodology development process so that we don't have that problem in the future and in particular with regard to the slide 105 information about the ROI for the program long results I don't want to be delayed and then have some issue where you know here we are again that's something we'd like to explore like I said in my remarks we had staff level conversations we did not have analysts to analyst conversations and I think to avoid that kind of confusion or surprises I need to have closer conversations with the people actually doing the data analysis as opposed to having it channeled through staff that would strike me as beneficial especially given some of the delays that have happened and the long running budget order on the slide 105 I think I got this right but what that means is if we actually look at that benchmarking report theoretically the ACOs that they're being compared to on any particular category could actually be in the first percentile and then one care would be being compared really to a floor on any particular theoretically that's right I will say that again I want to speak for them but one care doesn't actually recommend being compared to that 90th percentile group for that reason they say they do their overall results based on the median but that is not exactly what we asked for we were looking for high performers not average performers so that's why we're here we feel like we're not getting a high performer piece but they agree with that because when you look at those 90th percentile measures some of them are lower than the median for that reason and so that doesn't really mean that and if I could add to that Marisa I think we benefit as we work with one care or we hope to work with one care to refine the benchmarking report methodology to kind of address this issue chair Foster in part so that we can so that we can see a median I think seeing a median is is appropriate and important to say you know art is one care you know in the top also knowing kind of what the ceiling is as you know you say not know what a floor is that that will be really important I could see us using those measures and in particular the median as for purposes like performance benchmarking in the future where we actually are setting targets in ACO guidance as we kind of suggested so I think you know this gives us a sense that you know when cares just slightly above the median but they're actually very close to the 90th percentile like it gives us a sense of what the range is for any given culture really beneficial I don't think they necessarily should be held to 90th percentile in every category across the board that be outstanding but I think that's a very high bar however I think seeing where there's more runway for improvement and seeing if those are areas where we have particular issues in Vermont would be very beneficial I don't think the goal is to say if you're not hitting 90th percentile or failure it's to see where we can really target resources or where they can target resources to have the most impact for Vermonters so I think that would be beneficial to have it as you had suggested as by each category I didn't have anything else and you guys know I appreciate this very much I won't echo everyone else but thank you all and with that I'll turn it over to the healthcare advocate for any questions or comments thank you Mr. Chair I will be very very brief I also I want to thank the board staff and the board for really doing due diligence here you know yes the presentation is important but also there's a tremendous amount of work that's gone into this whole effort and also recognizing the board questions and focus here the HCA has an opportunity where you know we are pushed to write our thoughts down in advance and we did we made our comments and there's no reason to repeat any of those we stand by them and thank you for your work thank you very much Mr. Fisher unless anyone else on the healthcare advocate team has any questions or comments I'll turn it over to public comment which will be via the raise your hand function and I'll call on folks in the order in which their hands are raised Walter how are you good to see you please go ahead hey Owen spend a while yeah we missed you I know I missed you too what do I do with that my weekly dose of the Green Mountain Care Boards I think so you'd have two opportunities you did yeah I got two doses right Tom and Dave asked most of my questions and I thank Dave for the question about executive compensation I just wanted to follow up on that because that is excessively vague all those words are which Dave pointed out and I just want to know who determines that what these executives get paid because they're in their six figures now at least the top executives and they've got a huge payroll the second question I ask is the phrase appropriate utilization again what does that mean is that the fairly generic phrase two and I think that's a lot of the problems I had with this budget presentation and I echo the thoughts of everyone to the staff I think they deserve a medal of honor for putting this together but everything about one care is so vague and that's a big problem I have with it I'll stop here thank you for your comments I wanted to have you back I don't have the answers and I don't endeavor to answer every question that's raised I think and one care can connect with you if they'd like but I think the executive comp is determined by their board of managers I think and perhaps the CEO has input as to folks below their level I don't know that specifically sitting here right now but that's my general gist is that the board of managers will determine that but thank you for the question and comment anyone else great well thank you everyone for the presentation today with that I'll turn to whether or not there's any old business to come before the board any new business and is there a motion to adjourn so moved second all those in favor all right wonderful thank you everyone have a great day