 Okay, it looks like it's one o'clock and I'll call the Green Mountain Care Board's December 21st, 2022 board meeting to order today. We have two potential votes. The first relates to the 2023 Medicare benchmark rate. And then second, we have the one care Vermont fiscal year, 23 budget potential vote. And first, I'll turn it over to our executive director, Ms. Susan Barrett for the executive director's report. Great. Thank you, Mr. Chair. First, our ongoing public comment period on the all payer model, the next potential all payer model. I want to remind folks as I do every week that we are accepting any comments related to that next potential model. Any of those comments we share with the agency of human services and the governor's office as they are leading the negotiations on the all payer model. Second, I want to announce that the board issued a rate decision this week, and this was on Monday, December 19th. The board issued its decision and order approving modifications to Cygna's 2023 large group health and life insurance rate filing. The decision, the decision is posted on our Green Mountain Care Board website under what's new. And also on the filing page on our rate review website. With that, I will turn it back to you, Mr. Chair. I see a hand raised, Ms. Clark. That was an accidental click. I think I lowered it. My apologies. No, no, sorry about that. Okay. And with that, we will turn it to the minutes from December 19th, 2022, just this last Monday. We had a hearing. Is there a motion to approve the minutes from December 19th, 2022? So moved. Second. Is there any board discussion? Hearing none. All those in favor of approval of the minutes of December 19th, 2022, please say aye. Aye. Aye. And the vote carries unanimously. And with that, we will turn it to Sarah Lindberg and Lindsay Kil in connection with the 2023 Medicare Benchmark. Good morning. Folks able to hear me all right? Great. Lindsay, you want to do a sound check? Hi. Okay. Do you want to pull up the duck or shall I? I've got it up. Wonderful. Thank you. Would you like to take it away? Or would you like me to handle it? I can handle it. But break me off if I've gone astray. So here we are trying to vote on the 2023 Medicare Benchmark. To remind everyone on slide two, we are recommending the maximum possible allowable trends under the all payer model agreement, which is an annual growth rate of 5.2% for the bulk of our Medicare beneficiaries attributed to the ACO for their growth from 22 to 23. The very small ESRD population, a growth rate of 3.9%. We also are recommending to include the budgeted advance of $9.5 million that is used to help fund the Medicare portion of the blueprint for health programs, as well as SASH. So since we last spoke mere days ago, we were able to address a concern directly between OneCare and CMMI. So they had sent us a letter back on the 16th with their concerns that the base experience is too low. We were able to have the parties talk directly. And you know, I think that we all agreed that it's a tough thing to estimate, but that in good faith all parties will get that right if it ends up not being adequate. You know, everyone wants an accurate base trend. That is not what this is about. So that I did send a letter to OneCare with that kind of commitment from the Green Mountain Care Board side. So hopefully that will help in their efforts with their decision making process. And I think that's about all we had to say except for any questions you might have. Thank you very much. And so has this zone, I have one question. OneCare has had its opportunity to speak with CMMI regarding to the benchmark. Thank you for facilitating that. I have no other questions. Do any other board members have questions or comments? Great. Then I'll move to approve a Medicare benchmark of the staff recommended rates of 5.2% for non-ESRD and 3.9% for ESRD and to include the advanced savings of the 9,545,916 dollars for the blueprint for health and SASH programs. I will second that. Great. All those in favor please say aye. Aye. Aye. Aye. Aye. And the motion unanimously carries. Mr. McCracken, do you have your hand up? I was going to see if you want any board discussion or public comment on it, but I'm not sure that matters anymore. I had a sneaking suspicion I may have made a mistake. Your hand raised was a dead giveaway. So why don't we do that and do it properly? If there's any board discussion, please speak up at this time. Okay. And health care advocate, do you have any questions or comments? Nothing from us. Thanks, Chair Foster. And public comment, please don't let my jumping the gun get in the way of speaking up. So is there any public comment? Well, based on the fact that there's no public comment or any discussion that would alter our votes, I think the motion will carry unless any board member has a reservation about their vote. Great. Thank you all very much. Thank you. And we can move on to the next order of business, which is the One Care Vermont Fiscal Year 23 budget. And today we'll hear from Ms. Melamed and Ms. Sarah Kinsler. Thank you, Chair Foster. I'm going to bring up our slides. Thank you. So good afternoon again. My name is Marissa Melamine. I'm joined by Sarah Kinsler with also some help from Sarah Lindberg and Russ McCracken. I'm going to start off today with a recap of where we've been and what we have left to do in the FY23 One Care Vermont budget process. So the board has received some additional information since the deliberation last week. There are also several areas that we heard where there are board members still considering. There's some decisions still on the table. So we want to talk through those. We want to talk through the updates, the new information that we've learned, continue the deliberations on this particular areas around the risk model and the Medicare Advanced Shared Savings and the operational budget. Then we have the final conditions prepared. They should be posted and available for board members. Many of them have been sort of walked through and deliberated on already. So we're going to assume that there's no additional discussion there. But obviously, if there's anything that needs to be raised, this is the time, but we've prepared some slides on the areas that are still open. So the process to date or where we've been. The board deliberated on proposed conditions for One Care's FY23 budget approval or approval with modification on December 7th or December 14th. So please refer to that companion document that I mentioned. The significant new proposed conditions for FY23. So there are many conditions which are fairly that have become fairly standard. We've been through them. Probably no discussion is necessary, but we wanted to highlight areas that are new in FY23. So there's an updated condition on the ACO performance benchmarking tool. There is a condition around compliance with the Green Mountain Care Board review of the data analytics platform transition to UVM. We have set goals for fixed perspective payments. Those will be reflected in FY24 guidance, but we've also included them in the conditions for this year. There is a new condition requiring submission of an updated budget much earlier than usual, and that's to reflect some of the new information that's come to light around Blue Cross Boot Shield. So we'll talk about that. And then there are two potential conditions that are still up for discussion. That's a potential condition limiting the delegation of risk for the Medicare Advanced Shared Saving to One Care Network participants and a potential condition related to the maximum operating expenses. And then as a reminder, annual certification eligibility verification is still open and will continue into 2023 as discussed on December 7th and December 14th. So there are some open areas there around the policies around executive compensation and variable compensation and the analytics platform, and those are still being discussed. So the update on Blue Cross Boot Shield participation for FY23. So Blue Cross Boot Shield announced on 1220 that it does not plan to continue participation with One Care and FY23. We received formal notification of this shortly before this meeting from One Care that in the press release and such available online. So the Blue Cross Boot Shield announcement represents a material change to the submitted FY23 One Care budget. But we have to consider the budget that's before you, the budget as it's been submitted for FY23, which does include Blue Cross Boot Shield. And there's still the potential that the parties could come to in agreement, and we don't have information on what the material change would be. So we have to consider vote on a budget prior to the end of the year, but we've opened the possibility that this is a much bigger unknown than it usually is. We usually vote on a budget or the board usually votes on a budget without having completed payer contracts. That's the same. However, we have noticed that there may be a more significant change than is anticipated. So just as obviously we did not have time to do any substantial analysis on this change or require One Care to do any analysis on this change, but at a very high level, Blue Cross Boot Shield represents over 30% of the expected total cost of care. That's about $471 million in expected total cost of care and an estimated starting attribution of over 92,000 lives, how that actually flows through to the budget. We don't know exactly, but those are high-level numbers based on what we have. The Blue Cross Boot Shield press release states that it will continue to pay per member per month value-based payments to providers for attributed lives during the transition period, but we don't have any detail exactly what that means. And we don't have any information on how operating costs are delegated by payer program, if at all. So we don't know the effect on operating costs of a change like this. So that's why we have a new condition that One Care would submit a revised budget reflecting this change by January 30th if it comes to pass, that the parties are not able to reach an agreement for 23. We would need a resubmitted budget much earlier than we usually require that. And again, it's just another illustrative slide based on information we have around the participation, the total number of lives. There are 12 HSAs that we're planning to participate in the Blue Cross program and a majority of hospitals. I think I'm going to pass this one over now to Sarah Kindler for the next area. Thanks, Marissa. So I'm just going to speak briefly to the letter that the board received yesterday from One Care in response to member Lunge's request at the 1219 board meeting, which happened on Monday. The letter really expands on One Care's previously stated concerns related to both the risk model and risk for advanced shared savings as well as the board's previously discussed, previous discussions of its operating budget. So staff want to acknowledge these concerns, but we don't agree with all of One Care's conclusions. And so we thought it would be valuable to come before the board today to describe where we think these concerns and conclusions are real and where we differ. And then to make a final recommendation to you in this area, particularly in the area of the Medicare advanced shared savings and risk model. So staff think that the concerns that One Care raises actually drive home the need for One Care as an organization to expand their capacity to take on meaningful risk, both in support of continued smooth payment operations and kind of the cash flow concerns that they highlight in their letter and as a risk mitigation strategy for the provider network, particularly for things like the Medicare advanced shared savings that are not performance risk. If we can play out the scenario in which the risk for the Medicare advanced shared savings dollars had to be repaid, I want to highlight a few things as we go through that discussion and Sarah Lindberg will also play that out a little bit for you in another few slides. First, there's not a potential payout associated with this risk before fall of 2024. And this would give a One Care the opportunity to build additional reserves. In terms of how to build those reserves, we take One Care's comments regarding the line of credit and the potential audit impact. Seriously, and those are very helpful to us and make it clear that that in particular would not be a good path forward toward repayment. However, we do think that there are other mechanisms that One Care has to build reserves during the timeframe between now and late 2024 when 2023 risk would be settled. One would be hospital participation fees for 2024. In addition, One Care's letter states that holding back some shared savings that settlement at the ACO level would require renegotiating their provider contracts. But based on the materials that the board has available to it, we believe that One Care's policy state that the board of managers could choose to withhold some portion of shared savings rather than distribute it completely to risk-bearing entities. And I'm looking at there, I'm looking at the program settlement policy, policy 0407 for PY23. This includes specific reference to withholding money at settlement for contribution to reserves. In their discussion of these issues, One Care argues both that increasing participation fees or requiring an increase to participation fees late in the year would be effectively the same for hospitals as just holding the risk themselves. One Care also argues that it would create significant volatility for hospitals to pay those increased participation fees to cover any One Care losses that they couldn't otherwise cover. So staff feel that we can't argue both sides of that coin at the same time. So we agree that using some portion of shared savings at settlement to contribute to reserves would not be functionally different for hospitals than repaying losses at settlement for hospital held risk. However, under the staff proposal, this would be kind of a last resort rather than a first step. And it also sends a directional signal regarding the need for One Care to have sufficient reserves to ensure administration of provider payment models, expand innovative payment models, and make sure that they can do their core functions. Looking ahead, planning for One Care held risk in setting the 2024 hospital participation fees would actually create additional stability for hospitals rather than additional uncertainty. Finally, I want to note that right now, One Care technically does hold risk. They are the contracting entity in their arrangements with payers. Per One Care's reference in their letter to Rule 5, their mitigation strategy has been to fully delegate that risk to providers. However, One Care is not newly taking on risk if the board pursues this direction. Again, I'll hand it over to Sarah Lindberg in a moment to speak to the perception of asymmetric risk in the risk corridor. But as a nod to all of these factors in this discussion, staff are recommending a modified condition, which would which recommends a glide path for One Care for taking on the full risk associated with the Medicare Advanced Shared Savings and Out, specifically starting with the $3.9 million in 2023 that they currently have in reserves with the expectation that they would hold the full amount in 2024 and that the 2024 ACO guidance would make the expectation clear that One Care would budget for that in next year's budget. And so with that said, I would hand it over to Sarah Lindberg to add to what I stated and do her own thing related to the Advanced Shared Savings. Sarah Lindberg here to do my own thing on behalf of the finance team. So this is from the letter that One Care sent and it demonstrates their thinking about how this advance works and the asymmetry of it. So the first column is showing the blue above zero is the max upside risk and the orange below is the max downside risk. The amount tacked on for downside is that advanced shared savings. And so currently they're showing in the middle bar that it cuts into the upside potential for the ACO network and adds additional downside to their liability. And our proposal would minimize theoretically the liability to providers, but that One Care would still hold that risk. And so just so we're all clear, the advance is something that would need to be paid back if the entire risk corridor they maxed out the downside. So if you look on the next slide, please, I just have a different way that you maybe could one might think about it. And that is that it's upside 17 downside 17 with some rounding. And there's a 100% likelihood of that blueprint advance like that is going to get paid come what may. And there's this additional 7 million that could be earned. But I don't know if there's been any analysis about the likelihood of that scenario. And similarly, there's this downside risk. And that, again, I haven't seen kind of a risk assessment analysis of the likelihood of the magnitude of that downside. But it's not until you get to the bottom of that bar that you are paying back any of the advance. Theoretically, that's one way to think about it. I think that as I said, this is an alternate perspective on this. This is not this is clearly not the way that One Care envisions it, but this is another way to think about it in my judgment. So those guaranteed federal dollars have been demonstrated to be a substantial return on investment to Vermont medical expenditures. Several federal evaluations have shown savings associated with the blueprint per health and saving sash. I think there's only been one official evaluation of each. But I think that spillover effect that we saw in the most recent all payer model assessment has everything to do with these kind of investments. So these are things that are designed to help keep those expenditures down. There's nothing inappropriate in my judgment to holding providers accountable for that full downside risk. Like that is part of the deal of this whole arrangement that they've set up. But again, it's not until they went they were they're they overspent by over 3% that they would have to think about paying back the advance. So this is like a really big topic on my mind is like thinking about extending the concept of solvency to providers and how it really it's it's keeping risk but without some of the risk mitigation tools that insurers are accustomed to such as stop loss or reinsurance or other things that happen when something really hits the skids. And so I think that figuring out an appropriate way to reserve for our system is a huge conversation. And I think as regulators some of those decision points are does it make sense for each hospital to have more margin to reserve against that risk? Or does it make more sense to try to centralize some of those funds to help pool risk across our health delivery system? And that's where there could be a role for the ACO. But that is going to require some substantial thought and planning because today they just aren't structured to have a dedicated reserve. So you know some certain some important things that they would want to work on with us and other interested parties are you know where that money actually comes from. What's the guidelines around it? If it is depleted whose job is it to refill the coffers? Are there you know limitations around that? So I think there are a lot of governance and financial responsibility questions that I think need to be ironed out. And all that to say like I think that there is a lot of merit in a glide path in figuring out the right way to do this. However, at the end of the day the amount the total amount that one care Vermont may have to pay back is more than the total amount that one care Vermont would receive. So that is true but I don't know that it has to be necessarily you know I've been around insurance and health for a long time. I've never seen a scenario where it's like the right answer is to reserve 100% of the possible downside exposure. So I think that's kind of part of what we need to really think through as a regulated regulating entity. So on the next slide I just want to say that you know again there's not a lot of evidence that this is a major risk that that we're gonna like max out the downside. One care every single year that's been so we've only settled up to 21 but every single year they have gotten savings. So the blue bar on the bottom is the advance, the lighter bar stacked on top is the additional check that one care has gotten. You can see that bar gets a lot shorter and that's a function of that risk corridor so when providers are not willing to tolerate more downside risk that limits the upside risk and so that's why the bars have gotten shorter. You'll also see that they've been getting relatively more in advance. So again that's like comes quarterly in advance like that's we're guaranteed that money it's just whether or not if we don't do a you know if the performance isn't there that money is something that it has to be paid back. I'll also say that for every year except 19 they essentially maxed out their corridor so it's not like it's been super close in terms of barely getting there so you know I think that it is a risk but it's a very low risk that this would happen and I don't think that it's fiscally prudent to reserve for doomsday scenarios. So that's that's kind of I hope that's helpful and kind of framing this whole argument but you know the the headline I have is I think it does merit slowing down and doing it thoughtfully but that would be a good thing for Vermont to put that effort into think through. All right thanks. Thank you Sarah. I'm gonna I'm gonna pause for a minute. We have and Russ can help me where I need it. We have some suggested motion language on this particular recommendation. So we could vote now on this piece which was undecided or or seemed like there wasn't a consensus at previous meetings or we can wait and hear the rest the rest of the slides the rest of the information and stop and see what what we want to do on this. Ms. Melvin I think what I would suggest is we I will read the motion we will see if a board member seconds that and then we'll go to board discussion health care advocate and public comment and if it seems appropriate at that time we'll take a vote and then we'll move on to the next items so the order would be motion potentially a second and then discussion and then a vote unless Mr. McCracken feels that we should do it a different way. Nope I excuse me I think that's a good process. Okay I will move I will move to modify the staff recommended condition regarding risk of repayment of Medicare advanced shared savings payments to require that one care Vermont hold 3.9 million of the risk of repayment. I'll second that. Okay we'll turn to board discussion do any board members have any comments or questions relating to this motion or this topic. I'll go first I want to I want to thank Sarah for the explanation she really I think she walked us through that really nicely second when we when we talk about risk one of the things that I like to make sure I keep in mind is that in health care very few of us get to experience life risk free as patients or potential patients we are making decisions every day that involves substantial risk. As people who run businesses health care providers we are also dealing with risk payers are dealing with risk and what the evidence has shown over the past few months is that one care has attempted to minimize its risk as its assets have grown and so I can get in favor of the glide path approach for the reasons that Sarah laid out so nicely. But to try to have a business experience in health care that's devoid of risk. I I I'm not familiar with that. And so I think that this is this is a good compromise that's something that I can get behind. I think it's important in health care that we just think about risk as it affects everybody. Thank you chair. Thank you very much. I'll go ahead and jump in unless somebody else wants to go. All right. So I I'm comfortable with the 3.9 million in risk because it is an amount that has been held in reserves for some time combined with the fact that the actual payout is not for another 18 or so months 18 19 months which I think does give time for appropriate planning and discussion within the one care provider network. I like this approach for a couple of reasons. One you know we have heard for a number of years from hospitals about the asymmetric risk and the challenge that they feel in accepting that risk which to Sarah's point I think highlights the risk over the rewards scenario whereas this is up and downside risk. So given the performance where shared savings has been achieved in this program every year to me that should be weighing more heavily in the thinking of hospitals when they're thinking about how much risk they're willing to accept. And certainly I get that fee for service risk is what people know and what you know is more comfortable and that the ACO program still is a relatively small component of the hospital's overall budget when looked at individually. But I think that this is a modest step in the right direction to start address some of that thinking at the provider level and to the extent that we're looking for incremental movement forward and incremental change over time I think this is an incremental step in that direction. But I think I'll stop there. I don't have too much to add. I do support providing a glide path for the ACO to accept more risk. I appreciate this adjustment in the staff recommendation to the 3.9 which is what they hold in reserves. I think that you know as Sarah laid out consistency of the past savings results and you know the maximum Medicare benchmark trend that we just established for 2023 suggests that the ACO is not likely going to have to tap into these reserves to pay this back. So I think it's a gentle glide path for them to be taking on risks. And as Robin just said we have heard from providers over the years that these advanced shared savings impose additional financial risks that many of them struggle to bear. So to the degree that some of this now financial risk is now held at the ACO at least over the next 18 months I think it will relieve some pressure on providers particularly hospitals as they're you know undergoing significant in many cases financial strain. So I support this motion. Thank you for making it. Dr. Merman do you have any questions or comments? I have a comment it's I've been thinking a lot about this and have some thoughts on it. But I first I just really want to say thank you to the Green Mountain Care Board staff and just really excellent work over the last few months reviewing the ACO budget submission. Your work on the Medicare benchmark rate and all these informative presentations I think really helpful to the board and to the public. I think this is I think the overall understanding of one care's role in our health care system is a pretty challenging topic to understand. And I really do appreciate all the really well written public comments from various perspectives that that we had an opportunity reviewed. So as I said I've been thinking a lot about about this and gathering my thoughts on this topic I guess I kind of went back to the you know why am I here and what is my duty here and my my duty is I think first and foremost to for monitors to provide continuous improvements to health care access delivery and affordability. And I think what we need in order to do that is a high functioning and thriving health care ecosystem for hospitals and providers. But with regards to affordability I think it's really just really apparent that far too many Vermonters have difficulties accessing health care because of affordability. And and I just again this is sort of my general thinking approaching one care and this budget submission. And I guess today I feel compelled to share a story of something I think about often this time of year which is a tragic story of a patient who died in his attempt to defer cost of care. There's a gentleman that I saw around this time of year who had been having very concerning chest pain for months. His primary care provider is just there's call in notes and documentation on this tried to get him to get to a stress test. Had a cardiologist I believe call him tried to convince him to get a stress test intervention and and he deferred that. And somewhere around the holidays at a family dinner had a massive heart attack and came to me with CPR in progress and unfortunately did not make it. And I had extensive conversation with his wife afterwards and this has really moved me yearly at this time to think about this is that he he knew he had a problem and he was trying to defer taking on his cost to him all of the all of his copays and and what not until after the new year to try to cluster everything in the next year because they couldn't afford what he knew he needed. It's just tragic. I need to think about this happening in our country hundreds of times a day that the effect that we have that the high cost of health care have on patients and individuals and community members and specifically in this situation for monitors. So that's just the context that I guess that I'm thinking of all this sort of comes from this really strong desire to yes improve quality but try to think about this cost curve. And so when I've been thinking of one care I've been thinking of it in this perspective. Sorry. So I think that the challenge that I have in thinking about one care's budget and one care as an organization is trying to figure out how one care fits into the overall health care system. And I think that we've been thinking about one care. I have been thinking about one care in sort of an ideal way that they could use their ability and have sufficient risk corridors to reduce the overcall cost of care in a way that shared savings helps support Vermont hospitals providers to promote a culture of quality patient center care low waste low administrative burden of health care and incentivize payments for high quality sorry and provide high quality operational data to providers to reflect and adjust their organizations. It would free up money to that traditionally goes to services sorry that you would free up money to go to services that don't traditionally reimburse well like primary care care management transportation food insecurity. And it would incentivize care to be provided the highest value location. And I think of value again in this term of quality divided by cost. So a high value location is a high quality low cost it could be a high quality high cost would still be high value but I think of value in those terms. It could work with skilled nursing facilities to move patients from high cost in patient settings to lower cost settings that are more comfortable and have the services these patients need. So this is my dream of what I think I intended one care to fulfill and it's not that it can't do that it's it's not it's not an organization that can solve all of the health care woes that we that we struggle with in Vermont. And it actually has a relatively narrow scope and a relatively small potential benefit. And so I so I guess with that all of that in mind I really do think that adding some risk corridor to one care to incentivize the organization to engage in in the best that it can to improve quality and reduce cost of care for Vermont is for monitors is is the responsible thing to do. So I strongly support this. Thank you very much for those experiences. Dr. Merman I appreciate you sharing them with us. It's extremely impactful. I will also support this recommendation. I would be comfortable with a higher level of risk. But in light of the concerns raised and the staff's recommendation I am in agreement with it. I have one observation which is I thought that this process worked well. The staff made the recommendation. Member Lunge had some concerns about the basis to understand that which I think other board members did as well. And one care got to work to try and explain its position more thoroughly. And I thought that was helpful to the staff and to the board. And I'm glad that process played out as it did. I would also say that to me risk is not a bad thing. There is also reward and some of the decisions that have been made historically have limited the reward. And so I don't think it's necessarily risk aversion. I think in some sense it's almost reward aversion. If there was more risk taken on there would be greater reward and money paid out. And I think the probability of this risk side of it coming to fruition based on historical experiences rather low. And I haven't seen evidence or information to the contrary. So I think the system is meant for risk to be held and that is to incentivize and align conduct that will achieve savings for Vermonters. And so to me that makes sense and that should be how it works. And I'm okay with the glide path. But I would note that there is additional reward out there should people choose to take it. And that is the intent of the program. With that I will turn it over. Actually one other comment which is I would also note that historically and in connection with this year the care board has worked to maximize the benchmark which makes it actually easier to achieve the savings. The board is not recommended as 0%. They've recommended 3.5 and the opportunity to speak with CMMI has been provided. And so I think everything has been set up to make it very fair if not favorable for achieving the savings. And so I would encourage risk to be taken or reward to be available. And with that I'll turn it over to the healthcare advocate for any questions or comment. Thank you Mr. Chair, Mike Fisher here. I think I can just be very brief on this. First off I want to recognize that we did submit a written comment earlier today if anyone has not managed to see that where we cover this topic on a high level. But I will go to this level and say the HCA supports this approach. I would second what the chair just said. This seems to be working this process. And then I was about to just spend a second to really appreciate member Mermin's, I wanted to appreciate member Mermin's bringing a just the ground source, you know, the real life story to the table here. It's so easy for us in healthcare policy to lose touch with the obvious, you know, the effects that this self-care system has on real live monitors every day. So I appreciate that. But then I also, as I thought about recognizing member Mermin's comments, I thought, you know what, every single board member said something I wanted to second. So this has been a good conversation on this motion. I appreciate it. Thank you. Thank you very much Mr. Fisher. With that, I'll open it up for public comment. And as usual, please use the hand function, and I'll try and call you in the order in which your hand is raised. Ms. Loner, Victoria Loner, please go ahead. Thank you so much, Vicki Loner, CEO of One Care Vermont. I still want to point out that I think that there's a fundamental misunderstanding about the way that One Care was designed, in that as an ACO, ACOs are groups of providers. So ACO risk is provider risk. One Care was not created to be an insurance company. And I think if that is the conversation that we want to have, I agree with Sarah Lindberg, that we should be thoughtful about whether or not this makes sense for One Care Vermont to reserve like an insurance company, or if it stays in its current model. That's not a sole decision of the Green Mountain Care Board. That's something that One Care and its board of managers would also have to decide. With that, I would say that passing on this risk goes back to it as an ACO, who is a group of providers who are funded solely by hospitals. You are still pushing this funding responsibility on to providers. We have to have a source to replenish the funding. And that has been our hospital systems. So you're not creating more stability in the system by this. I do appreciate that you're opening it up for a glide path and that you're not expecting One Care Vermont and its providers to be in a position of potential insolvency. So I do appreciate that, but I still do believe that this board does not completely understand how One Care was created, how it's funded, and what its responsibilities are. And I appreciate Board Member Merman's comments that One Care isn't going to save all of the woes of healthcare. The reason why the All-Pair model was created, because it knew that it required a public-private partnership and that everybody has a role to play in it. The Green Mountain Care Board has a role. The state has a role. The insurers have a role. The healthcare advocates and One Care Vermont is part of that system. Unless we're all really clear about what those expectations are and we don't keep moving the goalpost, we're not going to get there, folks. And I don't agree that it's highly unlikely that this is going to happen. If we're paying attention at all to the current state of healthcare, it's volatile and it's not getting better. And we need to recognize that. Thank you. Thank you very much for your comment, Ms. Thoner. The next hand raised is Ham Davis. Please go ahead, Mr. Davis. Thank you, Mr. Chairman. I basically have a comment, but I've made it before, so I'll let that go for a moment. I'm curious whether there's been a lot of talk at the board about not just simply the three million or the nine million or whatever the numbers are, as far as risk bearing for One Care. What I'm curious about, there's been a lot of talk about One Care's performance. There's been vast criticisms of their salaries, of the way they function. And so my question is, let's assume that you're obviously going to pass this three-point, whatever it was, million-dollar risk for One Care. But will the budget order contain other issues? In other words, are you going to demand other issues in the way One Care operates? Can you tell me that, sir? Thank you very much for your question, Mr. Davis. The next hand raised is Tom Boris. Please go ahead, Mr. Boris. Good afternoon, everyone. Tom Boris, I'm the Vice President of Finance for One Care for the record. Just a couple of comments. I generally appreciate the direction this is heading and wanted to speak to the likelihood or probability angle as well. I know Vicki already mentioned it, but the maximum spend increase above target to fully consume this advanced shared savings amount is about 4.7%, roughly depending on where final numbers land. That's not out of the range of possibility. In the first year that we signed up for this program as a more of a next generation style program, the minimum risk corridor was 5%. So this would actually be a result within that original Medicare risk corridor limit or minimum limit. So this is just to say that the possibility that this happens is non-zero, and therefore, as an entity, we need to have a plan for this. So I just generally disagree with the statement that it would not be fiscally prudent to reserve for the doomsday scenario. I actually think that's being very fiscally responsible and making sure that we have the ability to afford our debts. So that's my first point. Second point is around kind of planning, process, building reserves, especially since we're provider funded, takes time and thought in terms of how that is done. And when we build reserves, essentially what it's doing is taking money off the balance sheet of one organization and putting it onto the balance sheet of one care. And in some cases, that might make sense. In other cases, that does not make sense. And I think that this type of shift, where moving from one care being a pass through entity of accountability to providers to holding it centrally at one care Vermont, needs a lot of thought in terms of how these reserves are built, from whom they come, how they're replenished over time. And it feels like this is being pushed through pretty swiftly without adequate time for us to really think with our network about how we might make this work and sustainable over time. And just to address the way that this is phrased as being perceived as asymmetrical, I just want to almost ask this board, if there's any remaining question about that, Sarah Lindberg confirmed it, but this truly is an asymmetrical design. And we've been very willing and happy to keep delivering these funds into Vermont to support the blueprint and support our providers. But it does have an impact on the nature of this program, particularly as it interplays with our providers relative to their sharing opportunity and their risk exposure, as well as ours. I just want to make that point that this truly is an asymmetrical arrangement. Thank you. I'm sorry. I may have mispronounced your name. Is it Mr. Boris or Boris? Boris, please. Thank you so much. Sorry about that. My apologies. No problem. Please go ahead. Oh, sorry. I was just thanking you for correcting my name. Oh, sorry. Michael DelTracco, please go ahead. Thank you, Chair. There's lots of moving parts here. I'll open by saying that. And we've heard some compelling conversations. I think all the board members that have been on the board for a while, many members of the public know that Vermont hospitals have been participating in value-based care and believe in the vision of what has been happening in the all-payer model. And it's been challenging. We've started this journey several years ago, got off to a start where we were standing up something new. We entered into a pandemic. I don't know that we know what the new normal looks like. And it's challenged this model from at many times. This conversation, to me, is another point or inflection point that creates some concerns or thoughts. I heard that this discussion of risk helps hospitals, and I heard the discussion of risk does not help hospitals or may not help it in the way that is believed by the Greenmont and Care Board staff. I think it's appropriate for me to ask the question about understanding that more completely. I think that it's too important to move forward with this vote without understanding that detail thoroughly. Our hospitals that participate in this all-payer model, as I said, we believe in this vision, or we wouldn't have been doing it otherwise, need to understand this detail. And it's because it's not insignificant. The amount of financial crisis that my members face is real and not insignificant, and if this adds to that burden, it would be incredibly problematic. Thank you. Thank you very much, Mr. Del Treco. Is there any other public comment at this time? Hearing none, we can have a board vote on the motion, which is to move to modify the staff recommended condition regarding risk of repayment of Medicare advance shared savings payments to require that one care hold 3.9 million of the risk of repayment. All those in favor, please say aye. Aye. Aye. Aye. The vote is unanimous and carries. Ms. Melamed, I'll turn it back to you. Okay, thank you, Mr. Chair. I'll move on to the next area of discussion, which is around one care's operating budget. So at our December 14th board deliberation, it appeared that a majority of board members are interested in the modification. We're still considering it at that time to the operating expenses of one care Vermont in the interest of fiscal responsibility and finding savings for Vermonters. Given that desire, staff believe that there's a reasonable modification that can be made as well as in light of potential new developments and revised budget. So we would expect that operating expenses would be adjusted in the revised budget. So at this time, we recommended administrative budget modification of a decrease in the amount of 2% subject to further reduction in the revised budget once that is reviewed. Some possible areas of achieving savings have been discussed and are listed here. They include base and variable compensation, vacancy savings, marketing and communications budget, contracted services, supplies, occupancy, travel expenses, underutilized data and analytics products, and administrative and or contractual costs associated with withdrawal of Blue Cross Blue Shield of Vermont, of which again, we don't have information on now but could include actuarial costs associated with finalizing targets, legal and operational costs. So this would be subject to further analysis based on one care submission of a revised budget in January. So we can now open this one up for discussion by the board that we have suggested motion language in front of you. So I think we can take this the same as we did the last one, which is we'll see if there's a motion in a second and then we can take it to any board discussion, healthcare advocate in public comment and then determine if a vote is appropriate. And so at this time, I'll move to modify the staff recommended condition regarding one care's fiscal year 23 operating expenses to require one care to reduce its operating expenses by 2% from its submitted budget. I'll second the motion. And is there any board members that have any questions or comments or discussion relating to this motion? I'll go ahead and go first. So given the big shift with Blue Cross, I'm not in support of cutting the administrative budget by 2%. I could see, given that we need them to resubmit and come back, directing them to come back with a revised budget that reflects a reduction in administrative in administration due to that, that if that pair program does not come to fruition, I quite frankly would rather see direction that the budget focus more on evaluation as some had suggested last time and or provider support for implementation of the clinical priorities. So from my perspective, I would say that we have seen one care evolve over time. I think that they tried to be too much to too many people in the beginning and that as a result, the programs that they were putting in place were too dispersed into there's just too much going on and it didn't concentrate enough in order to make the programs really implement quickly and effectively. Although I'm not as critical of the effectiveness as other people are. I agreed with their approach that came out of the APM improvement report and there's the one care strategic planning that they should focus on three areas network performance data and analytics and payment reform. I think those areas were areas which the NORC evaluation has indicated need additional support and in order to be effective. I think that there has been some incremental improvement in the data and analytics space that is reflected in their budget submission where they have revamped the reports and the data in order to make it more user friendly for lack of a better term. To me, the problem which we have known since the beginning potentially would be challenging is that we have had prior to one care Vermont a blueprint for health system which focused on local control over centralized data and policy priorities or clinical priorities. I think one care is trying to fit into that system which is required quite frankly by law and that as a result we may have some potential misalignment at the community level where the data and the clinical priorities responsive to the data are perhaps not as high a priority for that community as some other areas. Some other quite frankly potentially equally needed equal needs. So I think for me there needs to continue to be improvement and I think that there has been some incremental administrative improvement to focus down on the three key areas that I think one care should be focused on. I can't emphasize enough for myself how the pandemic has disrupted this program. So I don't see this as year five of an ACO program. I see that we had two years of an ACO program, two years of a pandemic and then one year where the ACO and the provider network are trying to get back into the the delivery system reform space. Understanding however that there still remains workforce challenges and other pandemic related aftershocks which have made it difficult for that to be the key focus. And so I'm not ready at this point to say that there has been fiscal irresponsibility and so that's why I can't support a two-percent cut although I certainly would expect that there would be some changes in the operating expenses and cuts related to the Blue Cross program if that does not come to fruition next and by the time they come back in January. Do any other board members have any questions or comments or discussion? I have some thoughts but I'm actually curious to hear others. Part of where I'm struggling is I think we all recognize there's going to be a budget resubmission in January that there are material changes to this budget with the withdrawal of Blue Cross Blue Shield. I understand we have to make a decision today to allow OneCare Vermont to contract and to commence fiscal 23 operations in January. So I feel as though in large part some of these decisions are really stop-gap measures until we have the final budget submission, the revised budget submission. I think it's going to be really important in that budget submission, resubmission to see how the elimination of one rather significant payer program flows through the budget with particular adjustments made potentially to operating expenses, actuarial contracts, payment processing, that payer program oversight and management, the analytics involved in the performance review of that program. All of that should impose some costs on OneCare but we don't have any idea what those costs are. So when I'm voting it feels like a stop-gap measure vote until January when we have full information. Could I support a reduction, a modest reduction in operating expenses of the magnitude of two percent? Yes probably but largely it's because I believe that there should be some expectation that there'll be a reduction in administrative costs associated with the withdrawal of Blue Cross Blue Shield. So this is my struggle is that I feel like I'm approving a budget that I know is going to be resubmitted presumably if we vote that way in a few weeks which will have much more information about it. With that in mind I guess if there is going to be such a resubmission I would like to see some resources allocated towards this program evaluation and provider practice transformation. I have looked at the most recent NORC analysis referenced in the ACO's most recent letter and while the NORC report does provide some high-level assessment of ACO and state-level performance of the all-pair model it doesn't really evaluate specific ACO programs or population health investments to the degree that I think is really helpful to decide if those dollars are going where we want them to go. It doesn't tell us if or how the CPR is changing resource allocations or the delivery of care at the ground level and I think that's the kind of program evaluation that the board has been looking for. I think the NORC report does show some progress as outlined by Member Lunge. It does also outline some gaps for example in awareness and usage of the OneCare Vermont data reports among clinicians which I do agree I think is something that OneCare is working to improve and it's much appreciated. Those reports are improving over time and I think there's a feedback going on between the clinicians and OneCare to try and improve the actionability of those reports. You know that's the type of an evaluation I think that we're looking for is what's working what's not. The NORC report also raises questions about the degree to which these new payment methodologies and or programmatic innovations are actually changing clinical practice among participating providers based on a survey that NORC did of clinicians. So I think again I think that's what we need a deeper dive into what data analytics are actually generating clinical changes what population health investments are changing care processes on the ground what's working what isn't and how can we scale up some of the successful innovations so they can gain traction elsewhere throughout the system. So that's what I'm looking for when I reference and when I speak about evaluation it's that you know 5,000 foot look at program evaluations versus the 40,000 type foot analysis that the NORC report does and lays out some successes and some opportunities. So that's where I stand on this. I'm welcome you know other comments and thoughts on this but this is where it's a struggle of it for me because the new information that we've heard about the Blue Cross Blue Shield withdrawal does change what we would expect those operating expenses to be. Mr. Walsh for Dr. Merman do you have any questions or comments? Dave you want to go ahead? Sure I mean I really appreciate Jess and Robin's comments and to struggle with how this fits into the budget resubmission I do think that trying to understand this whole return on investment over time and what the the financial value of one care is has been tricky. I also think really the important component that Jess mentioned the all the evaluations to figure out with the quality value ad is is is not clearly defined. That said I do think that we are in a time of significant expense within our healthcare system and trying to find any little place where we can save a little bit of money would be meaningful so I think any trimming there would be highly beneficial. I do also consider the importance of the executive compensation bonuses being in compliance with the guidance that there are specific and measurable goals to reduce cost and growth. Cost growth or improved quality of overall care of the role is both so that to me is somewhere where I feel like one care could have some measurable improvement. I think I'll leave it at that for now. If I may chair. Please go ahead. Thank you. I too want to thank Robin and Jess and Dave and the staff for their historical insight and analysis. Having listened I think the most salient thing right now is that there's been a big shift in the last 36 hours right and there's a new budget will need to come in. So I want to recognize that and show agreement with Jess. At the same time over the past few months I've come to struggle with this topic quite a bit. I asked in an earlier meeting leaders from one care to identify the outcome that they feel has best would best demonstrate the value they've provided to Vermonters and they could not answer that. I asked them to identify key performance indicators and they said after five years they've created committees to identify that. I asked if they could identify a care coordination program that was stood up because of data that said more effort was needed in a specific area and then what affected that program have and they can't answer that. I have looked over the past few months for evidence of data analysis. I haven't found any. There's data that need to be submitted to Medicare and Medicaid that involves entering numbers into a spreadsheet and submitting that. That's not analysis. It's definitely not millions of dollars of analysis. I haven't found evidence of a care coordination program or a population health initiative. I've found words that describe a desire to one day be able to do those things and yes there's been a pandemic and yes that that's been very very stressful on all of us. Many of us know people who have died. Healthcare providers have taken care of thousands of people that have died. Data analysis did not. That work had it been happening could have continued. It's remote work. So it isn't that that's been on hiatus for two years. There's been a long ramp for that work to be able to be started. In addition, in documents submitted to us from OneCare they have gone from touting their data analytics, their care coordination, and their population health efforts to describing themselves as a pass through organization. I've been trying to think about that and if I have a laundromat and there's money coming in and I'm saying I'm doing laundry and I've got dry cleaning out back and then there's money going back out of the organization we're six years in and there's no laundry being done. We've been buying the machines to do it and talking about how the machines and the people out back are all going to coordinate and do better, but I don't see any evidence of the work being done. Money's coming in and money's going out. That's a needed function for an ACO, but not a multi-million dollar function year over year. I would like I think there's room for a larger cut in operating expenses. As I said last week, I don't think that it's the role of the regulator to decide those cuts. I think that's a trap. I do know how socially responsible organizations elsewhere have addressed these type of concerns. They identify their core functions. They prioritize the safety, reliability, and population needs of the people they serve. They maintain revenue flow, of course, but they cut everywhere else. Most socially responsible healthcare organizations, those cuts, they prioritize clinical care and taking care of providers, but they forego filling vacancies, encourage early retirement, reduce the size of middle management, and voluntarily cut executive salaries. It would be telling if one care did it that way or they do it another way, but it's their choice to make. I don't know the exact number of two or three percent, but I know continuing to fund this organization the way that it's been funded feels wasteful. Turn it back to you, Chair. Thank you, everyone, for your insights and perspectives on this issue. I look back at slide 11, and it looks as though that there will be further analysis relating to the Blue Cross Blue Shield withdrawal in the revised budget that's being requested for January. I think this proposed modification in the name of affordability could go up should the revised budget indicate additional savings could be achieved for Vermonters, given that nearly a third of participants may not be in this program in 2023. On this motion, I would just say that my orientation is what's in the best interest of Vermonters. We do have a healthcare affordability challenge. There's significant public comment relating to concerns that this represents an additional layer and expense of bureaucracy in our system. I think Vermonters are looking for whether or not we're getting a return for what we're working for, and I understand the challenges with that, but if we look at the gross savings and losses over the years and we look at the data we do have and we look at the organizational chart and the performance that we have available to us and the presentations and the hearings we've had, I do not find that fiscal responsibility has been achieved, and I do not find that the budget as submitted has been fully justified. So I made the motion and I support the motion. I do think though that we've been, you know, the evaluation requests have been made for a period of time by member homes, by others, and the healthcare advocate, and they shouldn't come as a surprise, and I would say that they could be the best marketing for one care could ever have, right? If there is an ability to show, you know, tangible results that are meaningful for Vermonters, I think that helps quite a bit with commercial payers and with supporting the budget requests. And I would just ask that the board remain open-minded for next year's budget, that if we get information that indicates that one care is really achieving for Vermonters and it's working, there may be a need for a bigger budget. We want to pay more money if it's working. We do. And I think if one care can provide that information, the board should remain open-minded in the future that perhaps a bigger budget would be appropriate. But at this time in this budget, I don't have the evidence before me to suggest that the full $15.2 million budget is appropriate. So I support my motion. And with that, I'll turn it over to the healthcare advocate for any questions or comments they may have. Thank you, Mr. Chair. So we commented already in writing, and I'll say out loud that the HCA supports the concept of a modest reduction in the budget in recognition of a lot of what's been discussed just now. But I also want to step back from this just for a second and recognize that this has maybe more symbolic meaning at this moment than actual meaning. And that's not to diminish it. Symbolic meaning is important here. What are we saying or what is the board saying to Vermonters and to one care and to the healthcare industry? And so that is in part why I support the concept of a modest trimming. I think this is 2% something like $300,000 in that range. And so I think it sends an important message about the board's role here. But then I also want to say, and I recognize every one of us here, I think in this meeting is in this for the long haul. This is not just a one-off decision. You'll be back here in a month to relook at parts of this budget. And we'll all be back here. I'm afraid year after year, or I'm pleased to say year after year to look at our past actions. And so having said all that and weighing the complexity of it, the HCA falls down on the side of supporting this modest proposal. Thank you very much. And with that, I'll turn it over to public comment. And you can please again use the raise your hand function. The first hand raised is Mr. Del Treco. Please go ahead. Thanks, Chair Foster. Just going back to my earlier question about the implications of the risk discussion, I'd like to respectfully request that some information or analysis be done and provided on the impacts because I heard that it was a savings and a good thing to hospitals and maybe not a good thing to hospitals. And I think the provider community needs to understand that. So I'd like to ask for that information if possible. Thank you for your comment or your question. And we can get back to you. Miss Loner, I think your hand was raised next. Great. Thank you. Vicki Loner, CEO, One Care Vermont. I think it's important for me to go on record and I think I said this at the last meeting. I think that there is a fundamental misunderstanding by some of the board members on what One Care's role is supposed to be versus what the state's role is supposed to be in the LPAIR model. So that's number one. So before you start to have value judgments on what One Care has accomplished, we should be clear on what everybody's responsibility is in this system and what goals were created back when this model was developed. If you no longer see the value of an ACO, then that's a decision that the state needs to make. And let me remind you that we're talking about these high performing ACOs. I'd like to know who they are and why they're not participating in this model right now. Because as we stand, you have a coalition of willing Vermont healthcare providers that have decided to be fiscally responsible and join in One ACO to support the Vermont LPAIR model. So when you talk about what is of value, I was at a board meeting last night. We have 21 representatives on our board from across the state of healthcare providers. They do not agree with many of the sediments from this Green Mountain Care Board. They see value. They see value that we brought them all together to work as a system of care. That's value. Before we were working in fragmented systems and silos. Now they have those connections. We have saved, according to the North Report, in the Medicare program. Although you don't want to accept it, even the benchmarking tool shows that we are high functioning ACO. And that's thanks to Vermont healthcare providers that have been working tirelessly over the last three years during the pandemic, which this board seems to forget. So I'd like to say that as well. If you look at our quality, year over year, we're in the 75th percentile. That's a high performing ACO. That's not a low performing ACO. The North Report shows that we as an ACO are on target to meet the quality that the state has set forward for us. That's not nothing. In terms of our overall budget, to call us fiscally irresponsible is not doing your homework. We have reduced our budget by 1.6 percent. We are a low cost ACO. If you look at the MedPak Report, which is usually about 2 percent, in year over year, we have worked to do all those things, Board Member Walsh, that you talked about. We have not filled vacancies. We have taken cuts. We went through a strategic planning process to develop our core capabilities, which were shared with this board. Our data and analytics staff works tirelessly to do reporting for our network that is shared on a quarterly basis at the communities. And so I just need to go on record to say that all these statements are without fact. And I think it's important to introduce fact into some of this discussion. Thank you. Thank you very much for your comment, Ms. Loner. Dave Bellini, I believe your hand was raised next. Yes, could you hear me? Yes, sir. Please go ahead. Hi, I'm Dave Bellini, Ordinary Vermonner. I want to thank the Green Mountain Care Board publicly, Alia, for asking tough questions. And I think it's a new day. I was really surprised. I heard a little bit of, I think it was your last meeting. So I'm pleased that you're doing that. I can give you a perspective of someone who is at the hospital this morning, someone who has an aged parent. I don't know what the metrics are for one care. I mean, it's hard to understand what they do other than some monstrous process that they're proud of is for the average Vermonner. Are the wait times less than they used to be? I'm not seeing that they are. Has the cost of care gotten less? No. Access to care is still difficult. So I don't know exactly what they're supposed to do beyond some theoretical merging of money. But I would fund or not fund one care based on actual performance instead of the promise of performance. And they've been around for five years. So when you think the average Vermonner even knows who they are or what they do or why they're paid, what they're paid, I'll bet you 95% of Vermonners have no idea. So if you can't see it at the ground, if Vermonners aren't experiencing better healthcare, better access, lower costs, I don't think it's working. And there's an old expression, the dog won't hunt. So I'll just leave it at that. And thank you for what you're doing, Green Mountain Care Board. Thank you very much for your participation, Mr. Bellini. And I hope everyone's health and your family is okay this holiday season. Mr. Boris, your hand was raised next. Please go ahead. Again, I just want to address the data and analytics comments made previously and say, at least in my experience working for OneCare, the ACO is built on data. We literally cannot do anything that we do without it. This starts with evaluating reasonable total cost of care targets across multiple different payer lines, monitoring spend throughout the year, identifying opportunities for improvement, reporting comparative analyses to practices so that they can understand how primary care practice A compares to primary care practice B. We cannot set provider specific performance incentive standards in terms of earning bonus potential for high quality outcomes. We can't do our quality monitoring and quality collection. So I just want to go on record to say on behalf of all the OneCare staff who show up every day working really hard to try and improve the health care system. It is built on data, is built on hard work, and we're really here to try and improve the health care system as a partner with the state. And I just think it needs to be said on behalf of the staff. Thank you. Thank you for sharing that, Mr. Boris. And Robert Hoffman, please go ahead. Hi. Thank you, Chair. I just want to read briefly from the Medicare agreement, ACO shall implement processes and protocols that relate to the following objectives for patient-centered care, promotion of evidence-based medicines such as through the establishment and implementation of evidence-based guidelines at the organizational or institutional level. An evidence-based approach would also regularly assess and update such guidelines, including processes to ensure beneficiary caregiver engagement and the use of shared decision-making processes, coordination of beneficiaries' care and care transitions. The ACO shall require its initiative participants to comply with and implement these designated processes and protocols. And from their application to enter into this agreement in 2017, OneCare Vermont understands that care coordination within and across communities will rely heavily on creation of a functional statewide health information exchange for the clinical data in order to assess medications, problemless image reports, lab results, etc. And complex care coordination will be a key focus area at OneCare Vermont. I would submit to you all, nobody throughout the last three months will still acknowledge the significant confirmation that there's no clinical data available as confirmed in the NORC report so that ongoing continuous improvement at the institutional level can be performed as required by a contract to suggest that OneCare doesn't do care coordination to trace knowledge or demonstrate lack of knowledge of their own contracts. And to Member Walsh's point, they pervasively suggested that they were promulgating specific care coordination activities earlier in the contracts, and this year seem to suggest and have suggested in meetings that I'm aware of that they don't do care coordination. So it may be the case that it's happening out in the network, and I'm sure it is, but it's not been measured. And we can't look to a specific population level of intervention that was monitored and engaged in a quality improvement process so that then it could be brought back to this board. And to your point, Chair Foster, there would be no need for a marketing budget or there would be no need for the governor in the coming days to try and coerce the largest payer to return to the quote negotiating table, because they would be running into the arms of this organization to achieve the things which Miss Loner recently accused them of never having been able to do, which is improved quality, and I think that's debatable. But I would just encourage you all to maintain fidelity to this motion. I don't think it's symbolic enough. Mr. Fisher, I think it achieves novelty status, but to Dave Bellini's point will make no difference in his life for any of the family members he knows. It will do nothing to ensure that someone like the person, Dr. Merman, unfortunately lost and similar patients that I've lost who deferred care, it will do nothing to help them today. But I guess at a minimum, if we're satisfied with symbolic gestures as we head into the holiday season, I guess 2% would suffice. I think a much larger number would be meaningful and material, but at least the papers will be able to write that the Green Mountain Care Board did something this budget season to suggest that it's taking fiscal responsibility seriously. Thank you. Thank you for your comment. Ms. Aronoff, I see you have your hand raised. Please go ahead. Hi. Good afternoon, everyone, and for those in the midst of celebrating Hanukkah or tonight's solstice or upcoming Christmas and of course the New Year, I wish you all the best of holidays. I want to join the chorus of people really commending and appreciating the staff and the members, new and old of the Green Mountain Care Board. You guys work hard and you dig deep, and who knew this was so complicated? So the thing about it being complicated, the issue that I haven't talked very much about with this group, but I talk about a lot elsewhere, is healthcare literacy, the health disparities of people with disabilities. I would really encourage you to have a hearing sometime, Mr. Chair, on health equity work that's being done in Vermont regarding the disparities. Looking at health through an equity lens, our Department of Health has been doing brilliant work. Our legislature has been continuing that work. My boss, the Kirsten Murphy, Executive Director of the Vermont Council for Developmental Disabilities sits on the newly asked as the healthcare advocate, the newly established Health Equity Access Commission. I really highly commend you to their work and their reports. Health disparities for people with disabilities, I should say, I'm Susan Aronoff. I do policy work for the Vermont Developmental Disabilities Council. My focus is on healthcare access for people with disabilities. Playing language really matters. I just emailed you, Mr. Chair and Sarah, the welcome letter that I referenced in my comments. I don't know if it's possible to share it. It's a minor detail, but I would just implore you while you're issuing this order to consider two things. First of all, the letter is sent once and only once, so I'm a state employee. My husband was a Goddard employee. We each received letters once and only once, and oh my God, his has coffee spilled over it, and I honestly can't find mine. But anyway, there you have it. I think it's the kind of thing that should come every year because it does tell people even though you can't opt out of being attributed, you can opt out of having your information being shared, and this year, more than any other year, that ability to opt out of having your information being shared could really matter. It's not like UVM hasn't had healthcare information systems issues and challenges. Not their fault, I'm sure, but that's what happens with healthcare systems these days. Anyway, so one suggestion is, please just ask them to send it out annually, but the other, the more significant is, and this goes to Dave Bellini. Dave Bellini, by the way, was the state employee for 30-plus years and maybe president of the state employees union. He is an average citizen and he does have family members in the hospital, but he comes to this in this discussion as someone who's been up close and personal, especially with the state employees union's decision or lack thereof to have us all become attributed. So I've been told to find a different word for cash cow, because cash cow is impolite, but I haven't come up with one, but basically attributed lives are cash cows that drive the system. When you become an attributed life, you have no choice. If your primary care provider or, you know, UVM health network primary care owned primary care practices are in, then you're in and your healthcare provider is going to receive payments every month per member per month, regardless of if you go to the doctor once or 20 times. But if you're someone like me in their early 60s, you know, receiving first ever diagnoses of pre-diabetes and, oh yeah, my camera's off, but for, you know, in the disability world, I'd be giving you my visual description. I'm a 60-something-year-old woman, you know, overweight. Doctors don't want me in their panels. I'm not going to help them earn the benefit of, you know, people managing their A1C numbers, and I'm trying really hard. And we haven't tried a system yet that would incentivize me, but we're incentivizing our providers to have panels that have certain outcomes that our providers can't control. So the only way they can control it is a well-documented thing, and I didn't include the footnotes in my comments, and I'm really sorry. I'm sure you're all heard of, maybe have a hearing on this, the cherry picking and lemon dropping that goes along with capitated systems that really impacts the health of people with disabilities. So I would just encourage you look at that letter. It really does say there are group of physicians that come together voluntarily. It does not say anywhere, they're even a company. I'm not exaggerating when I say that. They should at least know one care is a company. They should know that their providers now have a financial stake in the outcomes of their healthcare. They should know they can opt out of sharing information, and they should be told that in plain language more than once. And I'm not going to bore you today with my comments about Medicaid, and gee, we should really know what we've invested to date and what we've gotten for it, because I and others have documented that. But to my knowledge, Mr. Chair, I don't think anyone except for me has addressed this issue of this plain language, and I think everyone knows, you know, the former chair used to tell one care, you've got to tell a better story. And then they blew up their publicity budget, and you couldn't read digger or go on to VP Vermont public without hearing about one care. But it's not like a public could buy one care. So I just thought that was superfluous and wasteful spending, and I'm glad this board and others have commented on, gee, do you really need to spend our money, Medicaid money elsewhere on PR? But really, this is an opportunity for them to communicate and tell their story. This is a letter every new attributed person gets, and they could get it every year. And it's a way to maybe welcome them on board and get them involved in their health care, do something. But don't, don't tell them nothing or mislead them. And by the way, it's really great when health care materials can be written in a grade level. That's like seven or eight below. And there's tools out there are easy peasy that do that. So please reduce the grade language level, get it out more often. And I'm not going to say tell a better story. I'll just say tell a more accurate story. Thank you. And everyone really have a good holiday. Thank you very much for your comment. I would just note that there has been robust, robust public comment in these hearings and in the letters that have been submitted by OneCare, by advocates, by observers, by the public. And I did want to take a moment to thank everyone for that. I can tell you that I'm quite certain I personally read every single one and a number of them are strewn apart across my desk, bookmarked, flagged, highlighted, noted, discussed with staff, discussed with staff again, discussed with staff again. And I think that that process adds a tremendous value to this. So I know people have very disparate views sometimes in this, but as board members, at least for myself, I really, really enjoy the engagement and find it valuable. So thank you everyone for taking all of the time to do that. It's an incredibly important part of the process. So thank you. And with that, I'll turn it over to Mr. McCracken. Thank you, Mr. Chair. We're going to do this by a roll call vote of members in alphabetical order and Chair Foster, you will vote at the end. I'll start with board member Holmes. Yes. Board member Lunge. No. Board member Merman. Yes. Board member Walsh. Yes. And Chair Foster. Yes. So the vote was four to one in the motion carries. Thank you very much, Mr. McCracken. Ms. Melamed, I'll turn it back to you. Okay. Thank you. And I may end up doing this in a little tag team with Russ to make sure that we we get it right. But the next part, go to the next slide for you, is so the remaining conditions, all of these we have walked through in previous presentations. So we didn't necessarily have slides on them today, but we want to make sure that we present them and show what you would be voting on. So I'm going to bring up a companion document, which I believe is also posted on our website. I'm going to stop sharing this. We can come back to the motion language when it's needed. So just be a second to switch the document I'm sharing. And while you're doing that, Marisa, if I can just take a moment. I know, Marisa, you said this at the outset, but I think it's significant and so it's worth repeating. We're aware, we became aware recently that there is a material change to one care's budget with the decision of Blue Cross Blue Shield not to contract with one care this year. The timing of this change coming about 10 days before the start of one care's next fiscal year is a challenge for the board's budget approval. Our recommendation is that it is important to the board that one care be operating under an approved budget for FY23. We don't know fully what the impact of Blue Cross Blue Shield Vermont not having a contract with one care will have for one care's FY23 budget. So our recommendation to the board and our view is that the best option for the board in the state at this time is to approve one care's budget with the conditions that have been presented by staff over the last couple of weeks and discussed today and that Marisa and I are going to walk through with you now. So we approve one care's budget with these conditions and included in here is a specific condition that requires one care to submit or advise budget by the end of January that reflects not having a contract with Blue Cross Blue Shield Vermont. And I know that this is sort of a material piece of it. This is our suggestion for the best path forward and there like I said there's a condition so if there are questions about that we can discuss them when we get to the specific language. But with that I'll turn it back to you Marisa. Thank you. So you should be able to see the document here or you can pull it up on our website. Let me make it even a little bigger for you. So condition one is around continuation of the ACO performance benchmarking tool that was implemented in last year's budget order and continued. We have applied some clarifying language in the condition this year to make our definition and understanding of the national ACO cohort or the peer ACO cohort more clear. Other changes include clarification around the comparison to the 50th and 90th percentiles. So I'm just going here for what's different. C is the same as it's been that the tool is meant to enhance one care's ACO level performance management strategy and integration of best practices into their quality evaluation and improvement program. That language hasn't changed as well as the requirement or the objective that this is a tool that would be used for regulatory reporting and performance assessments. We did lay out some potential guidance around target setting or performance benchmarks in the guidance for 23. But they were not binding. They were sort of let's look ahead. So we're including that language here. And again that was set in FY23 guidance. We would revisit this again in FY24 guidance when we will hopefully have another iteration of that report. We're asking for an updated benchmarking report by March 31st that meets the standards and methods for the report as specified by this order and the ACO reporting manual. We are also adding in here that the board chairs authorized to delegate authority to one or two board members and the director of health systems policy for the staff team to review and approve the proposed revisions to the report. I'm going to keep going through these just in the interest of time. If there is discussion or questions we can either hold them till the end or alert me because I'm looking at my other screen here so I can't necessarily see you. The condition 2 is the reporting manual. This is standard. This delegates standard reporting to a reporting manual which is allowed by the rule. So this is something that we've been doing for the past year or so so that we don't have to list out every report in the order. But there are some examples and some new things that are down in 2A here just to give you, you know, be illustrative around what kinds of things that are included in there. Audited financial IRS form 990. We've been working to transition a lot of our reporting into the adaptive database to improve our ability to analyze the budget. So we would like to move some more templates in there including reporting of full-time equivalents by ACO functional category. The reporting manual also includes FPP reporting which has been standardized and submitted over the years. So condition 2 delegates ongoing monitoring and reporting to this manual. We have condition 3 in here which is that one care month comply with the Greenmont Care Board requests pursuant to the Board's review of one care's plans transition of its data analytics platform to the University of Vermont Health Network. This was discussed on December 7th. Pair programs and risk. The first one or four is around, you know, one care designing their pair programs to qualify for scale and reasonably align in key areas, you know, as much as possible. This is an ongoing condition as long as we have scale reporting in the all-pair model agreement. The highlighted blue are areas that are new or were discussed today. So just to sort of highlight for you that we've discussed these. Five is the Greenmont Care Board's approval of one care's FY23 budget is conditioned on one care participating in FY23 in the Vermont Medicare ACO initiative and Medicaid Next Generation ACO program. One care must submit an updated budget to the Board for review no later than January 30th reflecting the effects of the Blue Cross Blue Shield of Vermont's decision not to participate with one care if that goes, you know, comes to pass. And Russ talked a little bit about the need for this condition. Six, again, is a standard condition around the pair contracts being consistent with the following 2023 benchmark trend rate. The Vermont Medicare ACO initiative trend factors proposed by GMCB, that's what you did this morning and approved by CMS, the Medicaid Next Generation ACO program are the trend factors that are established using the methodology consistent with the methodology reviewed by the Board in the Medicaid advisory rate case. And then commercial this, I think there's, well, again, this will come up with the revised submission and additional information about Blue Cross Blue Shield that may not apply. But I think we did add in a previous in a previous discussion. No, this looks, I'm sorry, this language is the same. Number seven is the ACO show you his best efforts to meet or exceed the goals for fixed prospective payments as adopted by the GMCB and FY24 budget guidance and identifying report specific obstacles to achieving those goals. This was discussed last week and we have some targets proposed there. Again, will be impacted by any commercial payer program changes, but these goals were for 24. Eight is around one care continuing to work with Medicare Advantage plans in light of their increasing enrollment in these plans over the next two years with a special focus on any plans offered by Blue Cross Blue Shield or UVM, MMC and MVP to see if these can be developed into scale target qualifying programs. Nine is around the risk model. So one care must implement the risk model that is described as proposed budget under discussion. Today was the new Medicare advanced shared savings risk requirement, which was passed in a previous motion. So that would be filled in there. The rest of this condition is standard that they must request and receive approval or I should say consistent approval with the GMCB prior to making any material changes. So one care must submit their contracts that find each of the risk bearing entities to one care's risk sharing policy and one care must notify and seek approval from the board as early as possible of any proposed changes to the risk model that is not part of this submitted budget. Moving on to the financials. One care must notify the board of any material changes. This happens during a revised budget process, but also if there are material changes outside of that process, the board must be notified. 11 and 12 are around the revised budget and the documentation. So because of potential changes, these conditions necessitate the two revised budget periods. So we will need to develop a submission for January 30th, reflecting what happens with the Blue Cross Blue Shield arrangement and then again a fully revised budget at the end of March, which includes the things listed in A through K. So the materials are submitted in March and then the ACO comes before us in the springtime at a date that will be set by the board and presents on their final revised budget, which should reflect finalized contracts, finalized attributions, finalized risk and the other things listed. Number 13 is the condition on the operating expenses, again in blue because that was discussed previously. So one care's operating expenses must not exceed the amount approved by the GMCB. As well, there's some language in here that one care's operating expenses for FY23 are subject to adjustment reflecting the withdrawal of Blue Cross Blue Shield and pending the board review of one care's plan transition of its data analytics platform to UVM. 14 is around the use of reserves and notification to the Green Mountain Care Board in the case of use of reserves and again the use of reserves, additional participation fees or funds drawn from one care's line of credit are limited to the five things listed here or pre-approved by the board. Under population health and quality, 15 again is consistent with previous years that we are approving the budget, the population health management budget. However, if those programs are not fully funded as detailed in the budget submission, one care must submit a revised proposal. Again, that usually comes in under the revised budget process in March, but if it's material to the earlier submission, then it would be included there any other time that a significant change is made. Condition 16 is around funding of the SASH and Blueprint for Health, so it's detailed out here as the 2022 budget amount plus the inflationary factor approved by the board. The new part here that was discussed today is that one care should hold at least 3.9 million of the risk associated with the Medicaid advanced shared savings payments and not pass that amount of risk on to any of one care's network participants and that motion did pass. Finally, 17 is a condition that's been under discussion for several years and stands and we discussed in a previous meeting around measuring one care's administrative expenses against the healthcare savings into the system. And finally, there is a general condition that the board may make such further orders as necessary to carry out the purposes of this order in 18 VSA 93, 82 after notice and opportunity to be heard. So Russ, maybe I'll let me probably should go back to the motion language. Maybe or do you want to say a word about how to pass this? Or I guess I should ask if there's any discussion and I should leave these conditions up or if I should go back to the motion language or do something fancy like split screen it. If it's okay with you, I wouldn't mind just taking a short break so members in the public can have a moment and board members can read this during the break if they want a little bit more time if that's okay with you. Okay, all right, we'll take a break until 3.10 then and thank you. Okay, it looks like we have five board members and our staff so we will reconvene the hearing. At this time I will move to approve one care's Vermont's fiscal year 23 budget subject to the conditions as presented today by Green Mountain Care Board staff with the modifications proposed and approved today by the board. I'll second. And with that I will open it up to any board member discussion, questions or comments. Being and hearing none, I will turn it to the health care advocate. I'd actually like to make a quick comment, sorry, I thought Tom took himself off so he had something to say. I just want to address like a few of the public comments off the last round. I think it's really important, Mike Diltreco I think brought up some of the issues right now that are facing hospitals in Vermont that are really significant and substantively different than where things were pre-COVID. The volumes are really up. It's very hard to move patients out of the hospital, get patients into skilled nursing facilities. The staffing issues are still there so I think that's a really important thing to acknowledge and I just want to say that this is something that I definitely think about and have several conversations with the staff about these issues and it definitely affects how I think about issues in front of the board. I also want to address Tom Borey's comment about the hard work of the one care Vermont employees and I by no means want to diminish the hard work that the one care employees do. I am sure and I have not met your staff other than a few of you but that your staff is incredibly dedicated and working hard and trying tirelessly to improve healthcare in Vermont and that does not go without appreciation. It is a hard thing to do and it's the impossible problem to solve and I just want to say that I personally and I'm sure the other board members feel this way just really appreciate and understand that hard work so thank you. I do think though that we are no longer in 2017-2018 when this started and I do think it is appropriate regarding the CO loaner's comments that it's time to move the goalposts a little bit. I think we need to keep moving forward because if this is where we are it's not enough. So I think continuing to just continuous improvement innovation is what I think we need in Vermont and trying to figure out how to do that as I think you mentioned is all hands on deck, all parties involved. So I just wanted to share those comments otherwise I have nothing really to say specifically about the motion other than I support it. Thank you very much those comments Dr. Merman I will echo them. It is an awkward situation when you're reviewing an organization's budget and passing judgment it is a difficult thing for the board members myself included to do and I'm sure I've been evaluated and I'm frankly evaluated now in a lot of ways. It's natural to not to feel a certain way about it and I think that is important for Dr. Merman's point that this is not to diminish in any way the hard work of any providers who are providing and keeping us healthy and dealing with a very challenging environment and I'm sure a number of outstanding employees and workers at OneCare who are working tirelessly tirelessly for us. I think the way the perspective that we're coming at it from is where are we where do we need to go and has the budget been justified based on the factors before us and the information before us. But I thank OneCare for its work in this budget process and for speaking up and providing us materials we needed to get here and for everyone's hard work. And I will say that the staff here at the care board deserves the same kudos. I know people don't really know how hard they work. I have seen Sarah Kinsler on late night flights jumping from one very difficult topic to another very difficult topic. Sorry one second. And the hours that the staff has put in to deal with five board members questions and information needs has been substantial. And so to the entire ACO team here at the care board, you have really really really helped all of us and we thank you for the many many late nights and early mornings that you've all put in. I have nothing else myself and unless any other board members have any questions or comments, I'll turn it over to the health care advocate. Member Walsh did you have a don't want to go ahead of you. Okay. Sam Pysh off to the health care advocate echo the kudos to the staff at the board. Just had a perhaps a bit of a clarification question. I'm wondering if there was a decision made to not include the previous recommendations that were presented on the 14th that include a requirement for return on investment analysis and program evaluation. And I'm still reviewing these conditions. So it's possible it was in there and I missed it, but we wanted to follow up on that. Thanks. Do you want me to respond to that or foster if you're prepared to please go ahead. The return on investment analysis is kind of the shorthand for the steps for condition 17. One cares administrative expenses must be less than the health care saving. So that is what we mean there. And then the evaluation requirements are in. So the benchmarking report is one evaluation requirement. And then the other ones we mentioned are reports that one care has said that they will prepare and we are going to request them. So I believe that would fall under the condition to around the reporting manual. We did not intend to remove those. Okay. Thank you. Thank you. We support the motion. Thank you. And with that we'll turn it to public comment. Hearing none and seeing no hands raised. All board members in favor of the motion please say aye. Oh Tom put up a Tom Boris put up a hand. Oh Mr. Boris please go ahead. Sorry about that. I was having trouble with my hand raising function. A little bit of a procedural question. I think having us resubmit a budget after letting the dust settle on this Blue Cross news makes a good logical sense. But despite this process I'm not giving up. I think I believe too much in health care reform to let this one die on the vine. So if we are in a position where we can resume discussions with Blue Cross I need additional time to work through that issue. Would this board be agreeable to adjusting that January 30th date dependent on the actual specifics of those discussions. I'll address that and I don't have authority to address this but I will say that we would be appreciative of any updates if there's any progress that is to be made. I have no clue if there is or there isn't. But if you have substantive changes in terms of where that lies please do call the staff and let them know and we can take up any requests for extension based on any of those conversations. Marissa or Russ or Sarah if I misspoke or you disagree please let me know. Okay I think we're prepared to vote then. All members in favor of the motion please say aye. Aye. Aye. Aye. Aye. Aye. Mr. Walsh I didn't hear your vote. Aye. Okay thank you. The motion is unanimous and carries. With that is there any old business to come before the board? Any new business? And is there a motion to adjourn? So moved. Second. All in favor? Aye. Aye. Aye. Motion carries. Happy holidays to everyone. Everyone be safe and we'll see you next time and the meeting is adjourned. Thank you.