 Good afternoon and welcome to the Green Mountain Care Board. My name is Kevin Mullen, chair of the board. And the first item on this afternoon's agenda will be the executive director's report, Susan Barrett. Thank you, chair Mullen. Welcome everybody. The first item I'd like to announce is that this Friday is the filing deadline for the qualified health plans on the exchange for 2022 and that is May 7th this Friday. We expect to see requests from MVP and Blue Cross Blue Shield of Vermont. I would ask folks to consult our website where we have a review page and it allows you to follow the process as well as any documents related to this process. The second item I'd wanna announce is that we have posted our schedule for May under our public meetings. It's a very robust schedule. Just a note that on May 19th, we have scheduled the primary care advisory group and that starts at 5 p.m. And the rest of the items are scheduled at 1 p.m. on Wednesday afternoon. But take a look at that. It's a pretty interesting schedule we have for the next month and robust. And then last but certainly not least, just to announce again, we have ongoing public comment on a potential next agreement. I'll pay our model agreement with CMMI. That is posted on our website. So we encourage the public to provide public comment so that we can share that with the other signatories on the agreement, that being the governor and the secretary of AHS. And we are sharing all of the public comments with our partners over at AHS and the director of healthcare reform at AHS as they are leading the way in the potential next agreement negotiations. And that is all I have to report out today. Thank you, Susan. The next item on the agenda are the minutes of Wednesday, April 21st. Is there a motion? So, second. It's been moved by Tom and seconded by Maureen to approve the minutes of Wednesday, April 21st without any additions, deletions or corrections. Is there any discussion? Hearing none, all those in favor of the motion signify by saying aye. Aye. Those opposed signify by saying nay. Let the record show the motion carried unanimously. So next on our agenda, we're going to move to Russ McCracken and Russ is going to talk about a couple of draft rules and talk to us about what he has learned since we talked about this a couple of weeks ago. Russ. Great, thank you, Chair Mullen. I have a couple of slides that I'll pull up here as well. So we're picking up where we left off two weeks ago with discussion of the draft data submission and data release rules. There were two open points, open questions that we took back and did a little bit more work on and so we're reporting back to the board on those two questions. The first one is in the draft data release rule and it relates to fees charged for data access and restricted data sets. And the draft rule says that those restricted data sets and access to the secure enclave environment are made available at the rate charged by the board's vendor to authorized users who can then pay the board's vendor who would then pay the board's vendor directly. And the question was, how does that comport with the state's procurement requirements and specifically bulletin 3.5? So we went back and took a look at that and the way that it is structured currently in the on point as our vendor currently and the way that that contract is structured which reflects what's in the rule is it's an IT contract with a zero dollar deliverable and that deliverable specifically is the restricted data set extracts or the access. And the contract specifically says that authorized users will pay on point directly for those data set extracts or for the access. And we're talking here really about non-state users because they're the ones who are charged a fee for accessing the data. And our view, our analysis after going through that again is that it is in compliance with bulletin 3.5. The on point contract went through the state procurement process as required in the bulletin that was approved by ADS's procurement advisory team. And any subsequent or successor vendor agreement would similarly have to go through the state's required procurement process to make sure that that zero dollar deliverable which is reflected in the rule is also done in compliance with bulletin 3.5 in the procurement requirements. There was a related question to that whether the fees are listed somewhere and the fees are included in the on point contract which is available on the board's website. The fee is $5,250 per extract subject to change over time and a one time set up fee of $550. Access to the secure analytic environment is set up in a tiered structure based on the number of seats per month. Currently only the state agencies and state entities have access to that environment. So it's not, that's may at some point in the future become relevant for non-state users but it's not currently. I can pause for questions on that or I can go on to the second followup point that we had. Do board members have any questions? I just have one question on do we know how many people use the services and how many $5,250 on point received? So this is Kate O'Neill I think can answer that question for you. We have almost 25 or 30 users accessing the data through the secure analytic environment who are state agency users and the fee for the monthly pricing that we pay for seats is paid for through the contract. The non-state entity users generally range in the low numbers like two or three users requests per year and the fee that is paid by a non-state entity is a one-time fee unless they need a refresh of the extract or if they're asking for something different during the period of time in which they are authorized to use the data and we allow, we authorize data through a data use agreement on a maximum of a two-year increment. Okay, thanks. Any other questions? Let's proceed, Russ. Great, thank you. The second question was really in response to a comment from Blue Cross Boo shield of Vermont and it relates to timing for implementation of any change to a data submission manual. The way that the prior graph that we reviewed last week works, any change to a data submission manual is done by making that proposed change known to the submitters, giving them at least 30 days of notice to review and comment on the change then the data governance council would review and has to approve any change. And then that's followed by a 90-day period that all submitters have to implement that change. And the draft of the rule said, submitters could request an extension of that period of time for good cause and they could have feel any decision of the data governance council to the board. Blue Cross Blue Shield asked that we look at extending that period of time to 180 days for compliance from the 90 days in the prior rule and in addition to provide 90 days for the submission of test files. And so we took that comment back and we understand certainly that there's gonna be a range of changes, some are certainly gonna take longer than others to implement. And so we're sensitive to that and think we would continue to be sensitive to that throughout the process. We also looked at a couple of specific scenarios for how long it would actually take a change to be implemented factoring in the 30-day notice period, the fact that the data governance council meets every other week. So any change that span two meetings would add an additional 60 days to the process. I also just wanted to correct you that the data governance council meets every other month. Every other month, sorry. Would add 60 days to the process. And so with that in mind, we looked at our timing again. We also took a look at the way some other states approach it, approach updates to their reporting manuals for their all-pair claims databases. Some states like Maryland update their manual on a yearly set schedule. Other states don't have the same yearly set schedule and they provide of the ones we looked at range from 120 days to 180 days for compliance. So keeping all that in mind and with some further discussion for the team, we suggest extending the period of time for implementation from 90 days to 120 days, following the data governance council approval of any change to the reporting manuals. And in practice, that's in addition to the additional 30 days review and comment period prior to a data governance council meeting. We're also suggesting that we revise section 8403 to specifically have the data governance council look at and consider comments from the submitters with respect to how long a change to the reporting manual will take to comply. And that's really to recognize that some changes may be onerous and might take more than 120 days, might take more than 180 days. But our feeling was not every change is gonna take six months to implement. So we thought 120 day compliance period was reasonable with the additional understanding that the, and there's a lot of words on the slide, but the data governance council will review comments related to the compliance time. We'll consider it and we'll extend that compliance time if determines that that's warranted. So I will pause there to take any questions on the changes to the data submission manuals. Are there questions? Before I open it up to public comment, Russ, would this require two separate motions or how do you desire us to proceed? I suggested one motion with some proposed language here that the board approves the drafts of rule eight and rule nine with the changes discussed which were on the prior slide related to the reporting manual. And that you instruct us to move forward with the formal rulemaking process to get both rules into that process and get that started. And I think we talked about it last week, but that process also includes additional public comment opportunities on the rule. Okay, so let's open it up for public comment at this point and then I'll come back to the board for further discussion and a possible motion. So public comment. Good afternoon, this is Michael Durkin from Blue Cross and Blue Shield of Vermont. I just wanted to thank the board for the opportunity to comment and I think this is a very reasonable approach and thanks for the timing consideration that went into it. Thank you, Michael. Is there other public comment? Hearing none, is there further comment from the board questions or a possible motion from the board? Kev, I have one just short question and maybe Michael or Kate can answer this more properly, but I'm just wondering, is there a practical example that someone can describe that would require a process with the 30-day comment period prior to the board's action and 120 days after? Is there an example of something that would really in the real world take that long? When you said Michael or Kate, were you referring to Michael Durkin from Blue Cross? Yes. Okay. I mean, Blue Cross was asking for the extension of the timeline. Michael, do you have a real life example? I don't have a real life example from practice but where I could see this coming up is when there's a requirement that is added where we don't necessarily have the exact field that we retain currently. So there would need to be a code written to map back to what the appropriate field is on our end. And I just from experience know that that process takes time and also coordinating to make sure that the requirements actually align. Kate, do you have anything further to add? I would only add that when we did our research and how other states are approaching this, it was similar to the way we've got the language worded now. And so although I don't have a specific example to share for you, Tom, I would say that it's pretty common to have a period of time to allow for implementation and for testing that would be sufficient. And we're lined up pretty well with most other states that we looked at. That's helpful, thank you both. Sorry, Tom, I jumped over you. I was asking you if that answered your question. And I was telling you that it did. So we were jumping over each other at the same time. Is there other board comment or questions or is there a motion? I can move to approve the draft Rule 8 on data submission and Rule 9 on data release with the changes discussed in our board meeting today as replacements for Bishka Rule H-2008-01 and that we instruct our staff and legal teams to proceed with the formal rulemaking process under the Vermont Administrative Procedure Act for both rules. Is there a second? I'll second. Is there further discussion? Hearing none, all those in favor of the motion please signify by saying aye. Aye. Aye. Those opposed signify by saying nay. Let the record show that the motion was carried unanimously. Thank you, Russ. Next, we're gonna turn to a discussion on value-based payments and their role, especially the FQHC and the all-payer model and the role of possible capitated payments. So we're gonna turn to Kaintland, Thomas Hindle and Art Jones. And if you could begin by just introducing yourself to those in attendance today and whenever you're ready to proceed, please do so. Thank you, Mr. Mullen. My name is Art Jones. I'm a primary care physician, worked with a community group and started a community health center on the west side of Chicago back in 84. And we transitioned from fee for service to primary care capitation in 1987 and I practiced under that for 25 years. And so speaking from that experience, we also were under an advanced alternate payment methodology in addition to primary care capitation. And then left in 2011 to create a Medicaid ACO, which I'm still chief medical officer for, which is 12 federally qualified health centers and three health systems in Chicago. We have 160,000 Medicaid beneficiaries that we are also paid primary care capitation and shared risk for total cost of care. So I appreciate the opportunity to talk about the opportunities to actually improve patient outcomes and improve patient access to care into that model. And I'll turn it over to have Caitlin introduce herself. Good afternoon. Thank you so much for having us. My name is Caitlin Thomas-Hankel. I'm a principal at Health Management Associates. I'm a clinical social worker. I have a blended experience, as I like to say. I practice clinically for a number of years in Massachusetts and Rhode Island. I also worked in state government and municipal government in Massachusetts and Rhode Island. And I've been spending the last, I don't know, about 10 years working as a consultant, supporting states and providers in value-based payment arrangements, behavioral health integration. I worked with a number of states on the state innovation model initiative through CMMI. And currently I do a lot of coaching on practice transformation and advancing VBP. So it's nice to meet all of you and we're delighted to be here with you all today. Before we dive in, I wanna check should I share my screen or is someone on your end going to share the slides? So Abigail, can you answer that question? Yes, it's preferred if you could share them just cause it's easier for you to talk over and forth but I am prepared to if you would like me to. Okay, terrific. I think I lost the button that said assume control or something in that regard. So let's see here. Abigail, I might need your assistance. I'm not seeing that control is not on my screen now. I think if you go to the dot, dot, dot in the toolbar, you should be able to find it. Am I correct Abigail? Okay, then I can share it. Okay, thanks, sorry about that. It's all right. All right. Everybody's seeing my screen, okay. Perfect. Yes. Okay. Okay, one thing to note up front, just in terms of terminology, we recognize that APM is a term that we use to mean one thing but recognizing that in Vermont, it has a whole nother meaning. So when we say APM, we're meaning alternative payment model whereas we know yours refers to the all payer model. So I just wanna say that up front when we say that just in terms of definitions but we'll do our best to not use acronyms so it's not confusing. So a few things that we're hoping to achieve today, you can see there on the agenda is really reviewing some state initiatives. We're gonna do an overview at somewhat of a high level to talk about some various state models for alternative payment models. We're going to speak to the limitations of fee for service reimbursement and how do you provide that optimal care as Art talked about, improving care for patients and really advancing that. And then we're going to describe an alternative payment model that's been used for both behind married care and behavioral health services that can be used to improve patient access to care. And finally, we'll touch upon those linkages between primary care methodologies and the expanded use of the primary care workforce and driving those two things that go hand in hand in tandem. Next slide, please. Okay, so we like to start with what is the data telling us as it relates to primary care? So this is an IOM report that's from 1996. So that was a long time ago, right? Doing the math over 20 years ago, this report laid out the foundation for primary care as being accessible, timely, coordinated, long-term and holistic to treat many of the most chronic conditions and majority of people. So population health approach and really reducing those obstacles for folks to obtain primary care. So that's what this laid out in 1996, this IOM report. If you're curious, I'd encourage you to check it out. Next slide, please. So let's look at what the data is telling us. So a report, a UDS report from 2019 looked at how are we doing as it relates to hypertension, diabetes and depression? And as you can see, over a third of hypertensive patients still have a blood pressure of 140 over 90, not ideal. Diabetics, almost a third of FQHC diabetic patients had an A1C of over nine, really not great in terms of uncontrolled diabetes. And depression, until recently with a lot of federal efforts that we're seeing with CCBHCs and other efforts at FQHCs specifically, majority of FQHCs were not tracking PHQ9s for depression on an ongoing basis. So definitely some room for improvement there. Next slide, please. So let's look at pre-pandemic, what was happening as it relates to trending for primary care among adults? So this data I wanna say upfront, this is from an eight year period of 2008 to 2016 and it is with a commercial population. However, some interesting trends here. So a decrease of primary care visits by almost 25%. So a decline, as you can see, primary care preventative visits increased interestingly by 40%, but that's only among one in five individuals. So it's distinct to a certain segment of the population. We'll talk a little bit more about demographics a bit there. And problem-based visits in addition declined by 30%. However, the proportion of adults with no primary care visits in a given year rose to 46%. So an increase, an 8% increase. And then looking at visits for low acuity conditions decreased by almost 50%. So I think it's some interesting data for us to pay attention to. Now let's dig into a little bit about pre-pandemic, what we were seeing among the demographics. So youngest adults, biggest decline there, 27%. Those who are healthy, right? Generally healthy without chronic conditions and living in lowest income areas. Now it's interesting, we're gonna talk about some healthcare disruptors later. And where we're seeing some of these, the Walgreens, the clinics, the across the nation really emerge, they're targeting areas where we're seeing some of these trends in terms of lowest income areas where they're setting up shop and different things. Out-of-pocket costs for this commercial population also rose 31% for problem-based visits, but declined for those preventative care visits. Specialists remained kind of stagnant, but, and we'll talk about this, visits to alternative venues. So urgent care clinics increased by 47%. And I can say in my state, where I live now, I'm a fellow former New Englander, but I live in New Jersey, we have seen a tremendous increase in urgent care clinics, the nationals setting up shop here, competing with some of the health systems that had had their urgent care clinics. So convenience is a factor we'll talk about later in terms of primary care and what we're seeing with trends. So what are other states doing as it relates to alternative payment model? This is at a high level, but we wanted to do a bit of a fly-by. And you may be very familiar with some of these. So Colorado established its regional accountable entities three years ago. Those RAIS, as they're known, are accountable for physical and behavioral healthcare of Medicaid members. In Colorado, they have a network for behavioral health services, primary care. They contract with community mental health centers, as well as private behavioral health. And as you can see there, there's a $4 PMPM for payment that's tied to specific quality measures. And there's also an administrative fee just shy of $16 that's paid as well. And that covers, that $4 covers the cost of coordinating care for members. And it's deposited into a pool and there are certain performance metrics in terms of getting some incentive payments. Connecticut has a PCMH Plus program. And for those of you that may be familiar with Connecticut, they have an ASO type of model, administrative services organization model. But this PCMH model is essentially, they have metrics such as ED utilization, wellness screenings, medication management, behavioral health screenings. They started with two waves, but they had to hold off due to the pandemic. In the year two, the performance there for three out of six of the quality measures was roughly just shy of 15 million in savings. And six of those 14 networks of the FQHCs and the CBOs earned the savings, a portion of those savings. Next slide, please. So Delaware is emerging in terms of they issued guidance, gosh, I think maybe six, seven months ago related to their APMs for Medicaid managed care that will begin this summer or they're set to begin this summer. That will include either a shared savings or a shared risk arrangement. So that's emerging in that we're watching closely. Idaho has value care organizations that share savings and losses. And that too was delayed due to the pandemic. And Iowa, Iowa planned to initiate their ACOs in 2016, but instead they shifted and moved to a managed care program that requires ACO in a risk-based arrangement. And there were some changes that were made due to low premium rates and some losses. So they had to do some recalculations to ensure that it was more actuarially sound. Maine, your neighboring state, as you may all be aware, you're probably familiar with the accountable communities program, shared savings. They have shown some savings in terms of created 6,700,000 in savings. And roughly just under a million was shared with the ACs still waiting for calculations. They haven't yet been published. And then Massachusetts Disrip, that model is one of the more complicated models I'll say. 17 ACOs across the Commonwealth participate. There's three different models that includes the MCOs and Mass Health, their Medicaid agency. And that includes 75% of their managed care members. And interestingly, they have a model that's very focused on partnerships with their CPs, their community partner agencies, that's really focused on complex individuals with behavioral health or those needing LTSS services. We're still waiting to see the financials for the Massachusetts Disrip program. And then last but not least, Minnesota is probably one of the models that's I'll say more mature, having launched it in 2013. And they've seen some outcomes in terms of their ED visits, roughly down 7%, hospitalizations, 400 million in savings to date. And Oregon, CCOs finally under their 1115 waiver, that program has 15 CCOs that operate all over Oregon. They have a cap, as you may be aware, 3.4% growth per year. And then their quality bonus pool has all kinds of various measures associated with it that the CCOs can earn related to behavioral health, primary care, other incentive measures. So that's an additional one we want to share. One thing to say about all these models, and I'll segue into art, is that majority of these models were built off of a fee-for-service chassis. So while there is still that strong incentive to drive volume in many cases, there's still challenges, right, in terms of with traditional billing and coding systems. So we want to mention that upfront that these are models, they're maturing, we're seeing them really change in transition over the years, the majority of them were built off of a fee-for-service chassis. And I'll now segue to my colleague, Art Jones. Thanks, Caitlin. So I think what you've seen with the various state efforts is some checkered outcomes, certainly nothing that kind of blows you away. And I think that really is you look over the last decade in terms of CMS and CMMI and all of their innovative payment methodologies, is I think they've learned, they've learned some lessons, there's been some success. They certainly have found that this is not an overnight thing that it takes providers time often three years plus to adjust to a new payment methodology and start to perform in terms of improve certainly financial outcomes. But I think what payers are increasingly recognizing is that perhaps we got the steps out of order. That traditionally what happens in value-based payment is you start with a fee-for-service system and you will pay for performance around some quality metrics and then kind of transition up to some short savings. Maybe put the providers at some limited risk and shared risk with the hope that eventually they'll get to population payments. But now you're seeing that these payers are recognizing that there is a limitation when you up through category three because it's built on a fee-for-service system. And so you're seeing, for example, CMS, their newest model, which is the direct contracting model which is catching lots of attention and lots of participation, is moving to add a minimum primary care capitation. You're seeing, I'm working in several states across the country with federally qualified health centers and their primary care associations to create a capitated APM. And because really, as long as you're under a fee-for-service system, you continue to chase the incentives that are related to that. With hoping it may be 18 months after the beginning of the year, I'll see some shared savings. But in the meantime, I have to pay my staff, I have to pay my bills and I'm used to doing fee-for-service. I think that not only are payers realizing the limitations that pre-pandemic, we also saw that providers realized that what they thought was safe, they made fee-for-service reimbursement was not so safe under a pandemic condition as well. But I think the real driving force about this is really in terms of population health and prunes of access. And so the real movement and the real rationale for moving to a capitated system is can I improve access to care? Can I improve patient outcomes? Can I better use my full care team to improve the health of our communities? So, you know, if you look pre-pandemic and you ask these questions, where providers asking patients to come in when a call or patient portable is advised, I think you'd have to say the answer is yes. And the proof of that is certainly now that we have pretty much, providers have pretty quickly pivoted and so have patients pivoted over to telehealth services. So certainly as we look back now, there's certainly more times we're asking people to travel, which is not always the most convenient thing, particularly for low-income people and particularly in states like Vermont, where transportation and travel can be significant distances. Is that, you know what? Yes, we were asking people to come in and sit in their waiting rooms when in fact maybe a telehealth visit would have equally sufficed. Was that contributing to no-show rates? I think we'd have to answer the question is yes. I mean, when our rides don't show up or something else occurs and we have other priorities, often with issues with family care, et cetera, is that if we could do that visit from home, then we're likely to keep that visit. And again, our experience in this last year during the pandemic with relaxed rules in terms of telehealth, we've really seen that the show rates have increased pretty much across the board and we're seeing much fewer no-shows. What's the financial impact though when providers turn around and do that? Particularly when they start to do what I think we want them to do, which is we really want patients to learn to self-monitor their conditions, to self-manage their conditions with support from their practices. The problem is to the extent that you do that, that's not reimbursable under a fee-for-service system that restricts payment to in-person or at least face-to-face visits with a billable member of the care team, not every member of the care team. So as we look across the country, there are examples of systems that have moved to a system that is primary care cap and actually capitated for most systems like Kaiser. And as we look at their experience, what they've done over the last decade plus is to move more and more of their encounters over to a virtual mask. My daughter's the type on diabetic. She was in the Kaiser system in Atlanta. She went from having to go and take off work to go see the endocrinologist to manage her type on diabetes, to go and seeing the endocrinologist once a year, the eye doctor once a year and her primary care doctor once a year. And all the rest of her diabetes and her management of her insulin pump and control of her diabetes was all done virtually by a non-billable member of that care team who was highly qualified and trained in helping her adjust her per pump. And I can tell you her hemoglobin A and C was never better than it was in that system. What's also happening across our market is that we realize that other service industries are pretty far ahead of where healthcare is. I mean, if you had asked me, five, 10 years ago, when I go on vacation, when I, instead of going to a hotel, would I be renting someone else's house? I would have said, you're crazy, but it'll never happen. I mean, I'm old enough to remember when the only way that you could go and see a movie was to go to a theater and there's still people that love to go to theaters and once a while it's kind of fun to go to a theater. But theaters show a movie at a certain time and it has to fit to their schedule, not to my schedule. And so we've seen that evolve from theaters only to blockbuster, which is now out of business to because it became more convenient for Red Box to go, for you to go to a kiosk and get the movie. And now we're all streaming the movies when they're most convenient to us. We've all seen with the retail industry is that our shopping has moved predominantly away from bricks and mortar shopping to online shopping. Banking, I'm old enough to remember when I used to take my paper check that I got issued twice a week, go stand in line at the teller to get my cash and paid for everything pretty much by cash or by check. We don't do any of that now. And again, so these other service industries have sort of redesigned themselves to make sure in response to consumers to say, what's the most convenient way for you to access my services? And if they didn't make that transition, they basically went out of business. Well, what we're seeing now in healthcare is those same individuals that have learned something in other service industries are partnering up with often venture capitalists out of the source of capital and with providers to come and say, we're gonna offer a different way of providing access to care. So a good example, I think one that what Caitlyn mentioned was Walgreens announced a little list a year ago that they were going to invest a billion dollars and start 500 clinics across the country. No longer clinics are just urgent care clinics. These are continuity of care, primary care clinics with 24 seven telehealth availability. They looked and sort of said, this is what the consumer wants. And they're not being paid on a fee for service basis. They're going and contracting with payers for total cost of care. So that they're no longer limited to say, yeah, it really makes sense for me to do telehealth but I'm worried that maybe after the pandemic that audio only telehealth is gonna go away. And so I'm gonna just stick to the in-person system. They are contracting in a way that allows them to provide the most flexible and convenient access to care for patients. And they are increasingly competing with other care providers based on this convenience model. At the same time, I think we're realizing and you probably feel this very acutely in Vermont is that there already is a significant primary care workforce shortage. The physician pipeline is totally inadequate as far as our future needs. And it's been made up to some extent by the increase in nurse practitioners and PAs. But the projections all is that there will be significant. There already is a shortfall particularly in rural areas and in low income areas in terms of primary care access. And that will only increase and get worse in the coming years. I mean, the data for rural settings is that now more than half of rural areas defined by 500 or fewer patients per square mile are in healthcare shortage areas. And that will only increase as our population ages, which means that it's the elder population that will take more and more time for primary care providers. And at the same time, the pipeline producing them. And I think we've seen that indeed often when there's those areas whether the rural or the low income that they have higher rates of uncontrolled hypertension, diabetes, obesity, et cetera. And that was a major contributor to the disparities we saw in terms of hospitalizations in death from the pandemic. So we're all more and more aware of the fact that there are disparities and we have to address this by looking at, okay, how are we gonna change the delivery system, particularly the primary care and behavioral health delivery system to really meet the needs and expectations of our population. Finally, I would sort of say that we've also realized is that for us to in medically underserved areas, rural areas, low income areas is that we need to take a care team approach. We've all kind of bought into the patients that are medical home approach, which is a care team approach that is more member centric, not physician centric. But the problem is that there are things that we could use other care team members to do in terms of tasks, but we can't do that because in fact, you know what, if we did that there's no reimbursement for it. So I think a good example is Caitlin showed you that for example, FQACs that more third of their patients had blood pressures above 140 over 90. And it turns out nationally if you go on the American Heart website you'll see that three quarters of patients with high blood pressure have a blood pressure of more than 130 over 80. So although NCQA is kind of used to cut off 140 over 90 what the American Heart Association says is that we should have people's blood pressure less than 130 over 80. That's only happening one out of four times. So what do they recommend? They recommend that patients get blood pressure monitors, they self-monitor at home and that they are supported from their practices. What the support from the practices means it could mean that, hey, you know what? If you're in rural Vermont support means that you check your blood pressure at home and then you get in the car or get someone else to pick you up and you travel over to my office and sit in my waiting room and I'll look at your blood pressure results. Or it could mean that in fact, support means that a community health worker who's very capable and trained in hypertension and lifestyle changes is having regular contact with that patient going over the results. And when in fact, the patient's home blood pressure results are consistently elevated and they're compliant with their meds and doing the best they can with lifestyle that there's a conversation between the community health worker and a nurse who then has a conversation with the primary care provider and they make a change in medication. None of that requires that patient to leave their home and go and sit in the patient in the provider's waiting room. So you can start to see that there are and whether that's hypertension whether that's diabetes whether it's depression whether it's asthma a lot of these chronic conditions can be managed. And I'm not saying that there's not a role for a face-to-face visit with primary care providers. We still, the majority of primary care visits if it requires you putting a stethoscope on someone's chest or feeling someone's belly requires an in-person visit but let's reserve those visits and reserve that capacity for people that need that. Let's not be eating up that capacity by things that other care team members can do and more convenient fashion for their patients. So the models that are evolving really are our collaborative care models where there is now a team approach between the primary care provider and a community health worker or between a behavioral health clinician and a community health worker that is making regular contact with the patient remotely. We've implemented that model for depression at our ACO over the last four years. We've had over 3,700 patients whose PHQ-9 was more than 10 with a confirmed diagnosis of depression who by enrolling in that program over 54% of them have seen their PHQ-9 drop by more than half and 34% of them have seen their PHQ-9 drop less than five which is considered a mission. Those are outcomes that are really hard to match any place in the literature. And we're doing that with a community health worker. Now with the traditional model as first developed used a behavioral clinician to make those contacts with patients between visits. You know, there's not enough behavioral conditions for us to be able to do that. We need them to be doing the counseling. Let's use community health workers to be contacting the members. And often because they're from the community those patients will relate to them and communicate with them. If there is a linguistic problem because they're speaking a different language and you get a community health worker that speaks that language, it's so much better than having to use an interpreter, et cetera. So we started with depression. We've now rolled it into hypertension. We're now starting to do it with diabetes. There's lots of chronic conditions. Or you can, if you think about where the model is gonna go in terms of nurse triage, right now for a practice to hire a nurse so that they can talk to a patient and sometimes say, you know, this is what you need to do. You don't really have to come in. Well, what I've done is I've added the expense of a nurse to in fact reduce my revenue under fee for service. So you start to see that a lot of the outcomes that we're getting and the fact that people are being pushed to urgent care centers are going to emergency rooms because we haven't set up the systems that allow them to provide access to care and support in the most convenient fashion for them in the most efficient fashion for us as a delivery system. So it's hard for me to look and again, I practice under this model for 25 years. So I was convinced early on, but it's hard for me not to look at this or say, you know what the current fee for service system is a barrier to reaching to maximizing patient outcomes. It's a barrier to me being able to use my full care team and the most efficient factor. It's a barrier to people having timely and convenient access to care. And we're realizing across the market is that there are healthcare competitors that are starting to that have recognized that are implementing models. And so we either have to change or someone will come in and compete with us directly, which maybe that's what it will take, hopefully not for us to get our attention. Oh, that's really from a primary care standpoint. So as I mentioned, our ACO, and I'll spend, I'm done here just a couple of minutes, our ACO is 13 FQA season three health systems with our 157,000 lives. The way that we get paid is we are paid primary care capitation for our primary care services. We actually believe that care management belongs at the practice level, not from a telephonic approach by a health plan. And so we are in CQA certified for care management and we are really delegated for care management down to our practice level. So those dollars flow down to the primary care practices who hire a community health worker and a care manager to do the care management of our complex patients. We do get some pay for performance around some of the quality metrics that the state thinks are important. And we're under a shared risk arrangement. So we have all the obligation to be able to say, you know what, we need to provide access to care in the most efficient manner so that we can reduce, we can improve the outcomes, be able to gain access to those quality incentives. And at the same time, do well from a total cost of care because we can eliminate some of the avoidable utilization and cost. So how does the primary care cap work is basically is you take, for example, if you were to move into this is you would take your primary care revenue from a typical year for a practitioner. So 2020 is not a typical year. You would take a 2019 and then you would divide that by the number of member months in terms of patients that were assigned to you as primary care provider. And then you would inflate that at a rate that is affordable to the state or to the payer. If the primary care provider, depending on their size, if they're large enough, then you don't have to add a risk adjustment pool because their risk adjustment is pretty stable from year to year. But in other places where there are small practices you would introduce a risk adjustment factor. Up to this point, risk adjustments have been pretty much based on disease burden, but we realize that increasingly that social drivers health have a lot to do with risk as well. So to the extent that we're doing in Chicago is we are systematically collecting social drivers health of information in terms of those barriers to care across our population. So we have about about a 90% compliance in terms of collecting information and we're increasingly using that for risk stratification as well. This is named as far as outcomes. So in Illinois, there are four, there are five health plans to do Medicaid. The one we're contracted with, we have 40% of their members, they were ranked the highest quality provider in the state. It based on 21 metrics, which are a combination of kind of preventive measures, chronic disease measures, but a lot of patient satisfaction measures as well using CAP score. And so they scored the top in the country of the 21 metrics. So our ACO outscored the rest of that health plan on 17 out of 21. So using this approach really has improved patient satisfaction with care. It's improved patient outcomes as measured by these metrics. And then in terms of other outcomes, I think you'd be interested in as we've now have completed five years of where we've actually been paid our short savings. We've been ended for seven, but you probably realize there's a lag again between when the year is completed and when you generate savings. But we've generated for our members that started off in the beginning and back in 2014, we had less than 100,000 lives. So it's gradually grown, but over that five year period of time, we've generated after paying for our back office, after paying for our care management is we've generated close to $80 million of savings. How do we do that? Well, we reduce inpatient days by a third inpatient hospitalizations by a quarter, 30 day readmissions by 12% ER visits by 11%. And you do that by increasing primary care visits by 10%. You do that by being responsible for total cost of care means that when someone's in the emergency room, as I make contact the next day and find out, okay, do they need to be followed up? If so, I get them in the next day. If they need to be followed with a telehealth visit, they get a telehealth visit. If it's really an education to say, hey, did you realize that, you went in there for your back pain or for your headache, but did you realize that you could have actually been much more convenient and you could have called the practice and that you would have talked to a nurse who either would have dealt with your issues or would have passed you on to a telehealth visit or would have said, if your condition requires inpatient visit, excuse me, in-person visit, that we would gotta visit the same day. So it's really doing that type of follow-up with patients to eventually let them know, hey, you have a better option than to be running to the emergency room for not-emergent issues. So I just wanna emphasize that what we've learned in terms of value-based payment, though, is that payment methodologies changes don't change outcomes. They facilitate outcomes and make it possible. So the models I've told you about are possible because of a different way of payment, but it really comes down to practitioners kind of deciding, you know, how am I going to change the way I offer access to my services? How am I going to relate across the continuum of care to work with specialists, to work with the hospitals during transitions of care, to exchange information in timely fashions so that we get better patient outcomes? Our ACO has a structure, and I won't spend a lot of time with this, but has a committee structure, it has groups that are working iteratively on a basis to figure those things out. What's our new model gonna be? How do we improve care management? How do we really take advantage and use the workforce? They'll turn the workforce more effectively. How do we train them? How do we exchange information in timely fashion? How do we engage our patients in managing results better? And then again, how does that turn into changing the incentive system that we pay our individual provider entities? So just to the last slide, this is our clinical committees. So each of our 16 practices chooses a provider champion that is responsible for coming up with this model of care for our ACO. So they spend half a day every week just on ACO activities. They sit on the clinical committee that meets every month for two hours, and they also populate along with other members of the practices, these other subcommittees. So you have a subcommittee that just looks at ED utilization, looks at the data, identifies the opportunity, comes up with a recommendation, which goes back to the clinical committee, and they say, yeah, this is the approach we're gonna take as an ACO to deal with frequent ED utilizers or et cetera. And then this responsibility, those provider champions, not only to approve the standard of care, but to take it back to their practices and implement it. So that's really what it takes for us to be successful. So I'll stop at this point and open it up for questions. Okay, questions from the board? I have a couple of questions, but if somebody else wants to go first, that's okay. Go ahead, Robin. Okay, hi. Thank you very much for joining us today. I had a couple of questions for, well, first in reaction to some of the data that you shared, Caitlin, you had talked about the decrease in primary care visits and also some of the disruptors. So my takeaway there was that not necessarily, to some extent, there were some people where there was no utilization, but it wasn't so much overall reductions in utilization. It was shifting, people were shifting where they got care. So instead of getting care from their regular primary care provider, they were choosing some of these alternative venues. Is that fair? Yes, absolutely. So yes, seeing a shift in terms of where they were going, increased use of urgent care clinics of the other types of models, yes, not. And this is, so let me say this upfront, pre-pandemic. So I want to just emphasize the timeframe for this was 2008 to 2016. So I want to note that as well, but Art, did you have an additional point? Yeah, I would just, and what that didn't show was, because it was practicing, it didn't show what was happening to utilization, which pretty many areas across the country was also increasing at the same time. So I think what you were seeing was that people were shifting to urgent care sites, whether it's the urgent care center or an emergency room for what really could be done in a primary care office. Okay, thanks. Yeah, and I think at least one of my concerns about that kind of shift would be continuity of care, really the patient having the support that they need for managing their own condition as well as having that relationship with the primary care provider. Yeah, duplication of testing and medical errors because the patient went to the urgent care center, forgot their bottle of medicines and then somebody put some on a different medicine that interacts with it. I mean, there's lots of problems with lack of continuity and lack of exchange of information. Thank you. I had a question about your delegated care management. I was interested in that model because we have, as you may know, in Vermont, a primary care medical home program called the Blueprint for Health, which is also paired with a regional community health team to provide those sorts of wraparound supports from mental health in other areas. And certainly with our ACO program, the care management is also a delegated to the practice level model. So I was just curious to hear a little bit more about that in terms of challenges, certainly I have my opinion about why Vermont kind of went that way, but sort of pros and cons of that model. Yeah, and I'm certainly like the Vermont model. I think the typical model across the country is it's done by a health plan from a telephone and that does not work. I mean, we're not going to change people's behavior unless we build a face-to-face relationship that they can trust us. Then we have built the building. So the advantage of having a primary care is that to the extent that there is a trusting relationship between the patient and the primary care provider is that the community health worker care coordinator or care manager can build on that relationship. It allows me as a primary care provider, when I see a patient, I think I'm managing the diabetes and hypertension, but they tell me about domestic abuse, that I can open the door and there is a care manager that can help me. It doesn't mean there's advantages to being out in the community because there's people that don't go into the primary care office. So we actually have a combination. So we have a hybrid model, particularly for our population that has an SMI or SUD diagnosis that's poorly controlled because they don't show up in primary care. So we have boots-in-the-round relationship with community-based care coordinators and care managers to manage some of that population. Thank you. And then my last question is really around whether either of you would have any thoughts on sort of what is appealing or not appealing to an FQAC in particular, as opposed to any other type of practice around sort of moving into a capitated model because certainly it's certainly something that has been slow to develop here in Vermont. So I'm just curious about what those pressures are from the FQAC lands in particular. Yeah. So first of all, to be able to really fully use your care team is really important. I think we also are from, if I'm an FQAC, I'm worried about can I compete with health systems in terms of my primary care teams? So I can't, I'll pay them in terms of salaries and benefits. I don't have the resource to do that. So I'm gonna have to, and that really goes not just for the primary care providers, but for other members of the care team as well. And so I'm gonna have to give them job satisfaction to be able to offset the fact I can't pay them as much. So to me, it's can I impact a larger population? I mean, I have a client, we did this model in Washington state. I had a rural area that one of the FQACs had an average visits of 1.8 when business per member per year, where everyone else was averaging three. Well, why was that? Because they couldn't get primary care providers there. So patients are going to the ED. So if I could use my primary care providers more efficiently and have other care team members do things that, you know what they're very capable of doing or I can train them to do. So I can do things that I'm most trained to do. That is a satisfying for me as well as doing a better job of improving the population health. And it's also just to note, freeing up the prescribers, freeing up the physicians and that job satisfaction there as well. So as Art talked about the clinical, there's a clinical transformation piece with this, right? It's not just the payment. You have to do the work in terms of training the staff, but the job satisfaction in terms of on the physician prescriber side as well as the MAs, your social workers, your other frontline staff and being able to do things more flexibly and work to the top of either their license or their ability if they're non-licensed as well. Thank you. Okay, other board members? Yeah, I have a question on the projected savings, the 79.3 million in projected savings. Can you talk about how those phase in and who's recognizing them and are people acknowledging that they are seen savings? So I guess if you looked at kind of how much are you getting each year? Yeah, so I should have changed. It's no longer rejected. I made that slide initially was projected. They've actually been paid now. So it's no longer projected. We got savings from year one. I think when you look at Medicare ACOs across the country, it's the exception rather than the rule to generate savings in the first year. Often you're not getting to like half of them generating savings after three years. There is a learning curve to this. We were just fortunate enough to be able to earn savings in the first year. Those savings are split 50-50 with the payer. And so like that last year, the year that ended in June of 20, where there was a little over 29 million in savings, the payer kept half of it and we kept half of it. We met our quality benchmarks. They kept half, we kept half. Okay, great. Thanks. That's all I had. Thank you. Thank you, Maureen. Other questions from the board? Yeah, I have one or two. Back on slide 13, where you showed the steps from fee for service at the first box to the fixed perspective payments at the end. I think making legitimate a point that weaning the system from fee for service is difficult. But that is the situation that I think we're in here in Vermont is we're on that path to try to do that. But one thing I don't think we have is any sense of what the proportion of payments should be that are fixed perspective payments that begin to kick in the benefits of access and innovation and efficiency that we all hope we can achieve. So just assuming that most people are on board that the network components that you talk about in terms of an integrated network are reasonably in place as one climbs that ladder to fixed perspective payment, what should we be looking for as kind of the guiding light in terms of how much that should comprise a provider's income? Yeah, yeah, good. I think I'm gonna answer that from two perspectives. If you look at what CMS has done with their demonstration they started with CPC, they went to CPC plus, they went to primary care first and then they went to direct payments. And what they found in each of those demos a higher percentage of the primary care practices revenue for Medicare patients was tied to capitation. And what did they get in terms of outcomes they got? They didn't get statistically significant savings on CPC or CPC plus is still too early for primary care first. But the reason they went to direct payment is they felt like, you know what? You can't have your foot on the dock and in the boat. Am I gonna chase fee for service or am I gonna do population health on the capitation? So that's one answer to your question. The second answer though really comes down to what percentage of my panel does this apply to? And that's where Vermont is so unique because the challenge is that for me if I'm gonna put in nurse triage, if I'm gonna do remote management I'm not gonna look at someone's payer class and sort of say, well, I'm not answering the call because you're with a commercial payer that's paying me fee for service and this Medicaid's paying me caps I'll do nurse triage for them. So to the extent that you can capitalize on your multi payer status in Vermont is a huge advantage for you because now I can put in one model of care which is what the practitioners are gonna do. They're gonna practice one model of care for their population. So I think it has to be on a multi payer basis as well. Well, so let me get a little bit more specific. We know that across the 14 hospitals here in Vermont that in terms of their net patient revenue about 14 to 15% of it is a fixed perspective payment or some kind of value-based payment. Is that enough or should we be at 20, 30% or 40% or? Yeah, yeah. So there's no magic to it but I guess my question would be is who's holding the risk? What often has happened across the country when there hasn't been success is that the risk has been held as the health systems and they're still paying their primary care providers and their specialists on a fee-for-service RVU basis. If the incentive down to them hasn't changed, you're not gonna get the outcomes you want. You have to change the way you're paying the people that are doing the actual direct care. So I'm not so sure that it is that percentage or this percentage, it really is more and that mistake is made. I mean, I have clients across the country that the health system say, well, we'll take the risk. We'll take the risk and just pay them fee-for-service and they're not doing very well but they kind of say, well, that's the cost of doing business. That's the wrong way, okay? The right way is to say, what incentive, what am I telling my individual practitioners seeing the patients as terms of what I value? And that's what has to change. That's the whole point about the primary care cap. Thank you. Okay, any other questions on the board? Sure, just a couple. Thank you so much for the presentation. It was really informative and helpful. I'm actually wondering a little bit about the timeline for practice transformation once the practice transitions from fee-for-service to capitation. It's obviously the design part is to reduce low value care and increase high value care. And I'm wondering, are there types of low value care that you see, the low hanging fruit that drops first, that other things take more time to develop? I'm just kind of wondering how that works, how quickly some of that value care has dropped out and what types of low value care you've observed being eliminated once the payment structure changes? Yeah, so I think the low value care are things like people going to the emergency room for back pains and colds and UTIs and things that because it's not, I mean, turn around and blame the patients instead of sort of saying, well, what's wrong with the system? Well, the system is that we didn't provide access or we said we had open access, but if you didn't call in the first hour all those slots were gone. So I think that is one of the first thing that goes and that's where a lot of the savings, I mean, most of the savings that comes out of these shared savings program is related to hospital revenue, okay? It's another big thing that drops is that we don't do a good job of managing people after your hospital discharge. So there's not good communication. People go home, they had one bag of medicine home, now they come home with a second bag of medicine, they don't know what to do. So there's no one's doing the med reconciliation, no one's making sure that the information from the hospital gets to the PCP or the behavioral clinician when they follow up and they often don't follow up. I mean, I can tell you from before, as a primary care provider, I treat somebody and it was before the day of hospitals, I took care of my own patients in the hospital. I thought I explained to them that you need to go fill this prescription for an antibiotic for your pneumonia and they come back three days later with prescription in their hand. It's that kind of thing where it's just like, okay, we're failing. Somehow I'm not communicating, we're not doing a right job and that's where community health workers who maybe can do a better job than me and really managing transition care and working with patients to self manage themselves. And then I think you get to these things like, okay, does it really make sense for me to drag somebody in here to get their blood pressure checked? I mean, 20% of people, when they walk through the front door, their blood pressure goes up. And as a PCP, I don't know, am I seeing is your blood pressure up because you have white coat effect or is your blood pressure up because it's always up? I don't know, I'll guess and I'll change your medicine. If I'm wrong, then I've got you on too much medicine. You go home and you feel weak and dizzy and then you blame the doctor and stop your medicine. Like, are we really that surprised we're doing a poor job of managing hypertension? It's just not a sane system. So I guess my follow-up question then would be, is there an upfront investment amount that you've identified prior to transition that would really aid these practices in, for example, they have to change their entire business model. They have to restructure staffing, make sure that they have relationships with behavioral health, make sure that there actually is a psychiatric provider that is even in the area that can be accessed. They may need to invest in remote monitoring, telemedicine. I mean, all of these things taken up front investment. And so I'm not talking about the PMPM for care for, and I'm talking about like before you even begin, you're changing the business model completely and that requires investment. Is there any evidence on what that amount needs to be, you know, per capita or how do we get our hands around that? And without it, is it possible? Yeah, so in 87, I didn't have the luxury of having an investment. Do I think there needs to be investment? Yes, but there also has to be, okay, the first step for me is to look at what do I have my staff doing now and how does that change when I change the reimbursement system? So first thing you don't do is go hire a bunch of new staff. You first kind of look and sort of say, how do I repurpose? Like what's my model of care? So you need some time before you, before you jump into the capitation, you should be doing some planning. What am I gonna do differently? Cause if you don't do something differently, you're not gonna get different outcomes, okay? So it's gotta be that time for planning. And then there has to be, okay, let's look at the job descriptions and the workflows and let's see what I can do with the staff I have. And then yes, you need to, there needs to be some investment. I don't have, I can tell you, our experience is that we started paying that care management fee upfront and we had some infrastructure dollars that probably amounted to, I mean, it's blended because it's higher for complex patients and other, but probably amounted to like $10 per member per month that gave them enough money to start to say, okay, now I'm gonna do care management, now I'm gonna redesign care. And it is an iterative process. It is year after year. You don't suddenly just jump and do everything at once, but you do something one year at a time and you gotta make sure that you're getting some of the savings on total cost of care then you would reinvest those savings into continue to change your practice model. Got it. Two more questions and then I think I'm good. One is you've mentioned telehealth and the values of telehealth and in terms of increasing access and better disease management. I'm just wondering, there's probably some trade-offs there in the sense that it may have potential to increase costs in the sense that while there's fewer no-shows, so then those are visits that are actually gonna cost money, which is, I mean, a good thing that people are getting care. So I don't wanna undervalue that, but there's also some anecdotal evidence out there, I think and maybe some evidence will come out post-COVID about more specialty referrals that come from telehealth that may have been managed in the office without that specialty referral and also I think just came out the other day that nurses have a higher workload around telehealth and more administrative burden. So I'm just wondering what does that mean for burnout or workforce shortages? And so I'm just kind of thinking about how do we weigh the costs and benefits of telehealth in terms of access costs, burnout, workload and all of that, you know, it's worth thinking about this as a new model. Yeah, very good question. So what we did prior to the pandemic is we kind of figured out a care team approach and we had workflows and we had responsibilities and then suddenly the pandemic was upon us, all right? And we had to pivot in literally what, two weeks to start to offer telehealth. And as a result, we didn't have the ability, the time to actually do the redesign to sort of say, how are we gonna take a team-based approach to telehealth? So that's, and then that leads to burnout and it's not just the nurses, I'm hearing it from the providers themselves to sort of saying, you know, I didn't used to have to do this, now I gotta do this and they, I don't like telehealth because I gotta do things that somebody else was doing before. So there's that issue. There's the issue in terms of what's gonna get paid for after the emergency period for telehealth and so the problem with audio-only telehealth is that it's much more open to abuse and that's what the payers are saying. On the other hand, if you're in Vermont and you're in an area that doesn't have high-speed internet, okay, or you're in a low-income area that can't afford the devices or has, doesn't have unlimited data, man. So you've taken on this with your visit, okay? It doesn't work as well. I'm concerned there's gonna be more disparities in outcomes now based on the revision and telehealth rules. Well, the way around this pay primary care cap because now what you've said is here's, here's how much it costs us to provide access to primary care. Now, if you wanna do it over an audio-only telehealth you wanna do it video with audio. If you wanna do it over the patient portal, if you wanna bring them in face-to-face, work it out, work it out, what's most convenient, what's gonna get you the best outcomes and it doesn't cost the pay or anything more and you can be more efficient to sort of say, well, some of the stuff that I would have to use a dog for I'm gonna use a community health worker for. As long as it's clinically appropriate and people are trained, let's use a care team approach. But I think in less, and then it has to be tied in my mind primary care cap has to be part of a total cost of care contract. I think you use the two APMs together, right? Now I'm incentivized to sort of say, if you pay me primary care cap, I'm having incentive but I'm also under shared savings or shared risk. I have incentive to make sure I'm providing such good access people aren't going to the emergency room. And when I do a good job of keeping out of the emergency room, there are dollars to help me pay for that nurse as well. So I think you put the two of them together and you always have a quality component that is detecting if there is under provision of care. That makes a lot of sense, I appreciate that answer. My last question is just around, you had talked about the capitation peru at an inflation rate and I'm just wondering, a lot of states, including unfortunately Vermont, often the medical expenses don't rise from Medicaid, don't rise with the cost of medical inflation. So I'm wondering, has your experience been that the capitation has risen with the costs of delivering that care and risen at the rate of medical inflation or no, and what should the appropriate, how should you tie that inflation rate? How should that inflation rate be set? Yeah, so I think first of all is that it realized that fee-for-service PPS rates for FQCs have risen at what's called a medical expense inflation factor, which in any one year is like 0.8% to like 1.5%. I mean, it's nowhere keeping up. So in some states that I work with that move their FQCs to capitation, they allow one-time rebasing where they do a cost report and bring their fee up to where it should be. And then they decide, okay, what am I going to inflate it at? So Washington state doesn't inflate the MBI. They inflate it a little bit higher than that. You decide as a state. You decide as a state, okay, if you're like Oregon, do I peg this at 3.4% growth? And that's what I want to do. And you peg it to whatever you want to increase as a state. But you can't inflate it at less than 1% expected. It's going to keep up. Okay. Thank you. Very helpful. You're welcome. Thank you, Jess. Robin, I understand you have another question. Yes. Thank you. I was curious in your ACO program where it's a mix of FQCs and health systems and hospitals. Obviously you're generating the shared savings from reduced utilization at the hospital level. How do you keep the hospitals in the ACO? Yeah. So first of all, the hospitals have employed primary care providers. And so they're benefiting from that. They also have specialists. And we use e-console, for example. So we figured out what's a more efficient way to use our specialists. I didn't have time to go into all that, but we look at how do we provide access to specialty care as well. And then also, unlike Vermont, Chicago's a pretty competitive market in terms of we're over-bedded, right? And so either you move down a path of being more efficient or you're going to become the next Kodak, right? I mean, so you have to kind of think. So if and quite frankly, not every hospital was interested in partnering with us because they didn't have the vision. Then in fact, their future had to be that they were going to differentiate themselves by being high-valued. So our partners have that vision. Thank you. Okay. Anything else from the board? At this time, I'm going to open it up for a public comment and I'm going to turn first to Walter Carpenter. Hey, Kevin, thanks much. Thanks for the presentation. I just wanted to make a comment more than anything and I'll just talk about payers. It should be noted here that we, the people are the payers, not the insurance companies or the public or Medicare or Medicaid, but we are the ones, they disperse it. Right. And it's an open question whether we need them or not, but in any case, so when you say the payers get 50% and the physicians get 50%, if they come over budget, then why aren't we getting that 50% because we are the ones who are the payers? Yeah, good question, Walter. And you're right, you are the payers. And so, and what's happening around the country is you as the ultimate payer and the consumer are demanding better service, okay? Actually, what happens when we reduce total cost of care is the next year, the premium gets adjusted down. Who's paying for that premium? Taxpayers are paying for that Medicaid premium. So to the extent that we're more efficient, okay? And we drive down cost and they turn around and they do readjust the premium accordingly. So that is a way of making sure that it's coming back to the ultimate payer, which is you. Well, the real problem is our costs are going way up. You know, every year, insurance companies ask for a raise, hospital fees go up. Our wages don't go up. Yeah. So I am certainly sensitive to that. I'm not an expert on the Vermont model so I don't want to comment on the Vermont model, but. I just wanted to make that note. Thank you. Dale Hackett. Yes, sorry, took me a second to find the mic. I'm very curious on how you do, in fact, interact with the specialists. I have a lot of specialists for examples and I find that that's a real backbreaker is trying to get the primary care office and the specialists to actually communicate in order to create that plan of management on the primary care side. The other one I'm curious about is whether or not you run into workforce shortages. I thought I heard you say maybe once or twice that you did, but then again, it sounded like you had plenty of workforce. The other one is I did notice this like when I used to go to healthcare in Canada, everything was in one place. This is years ago. Your pharmacist was right next to your doctor's office. You actually didn't have to move around that much. It was almost like there was a small mall that was nothing but healthcare. Because you mentioned Walgreens and how would they do deal with workforce shortages if they're gonna offer services? But the other factor is when I call up to schedule an appointment, I often don't get my primary care doctor, but I get somebody on the team if it's an appointment that needs to be that day or the next day, I'll often say who's available. That's good enough. As long as they can manage the issue, that's good enough. I'm just saying it usually isn't the primary care doctor. That would be a two week out appointment. So how do you deal with those type of logistics? Yeah, all good questions. So let me start with the first one. Actually, it's the specialist. So under a fee for service system, the specialists only get paid if they see you face to face. Well, it turns out that we implement what's called e-consult, which is secure messaging between primary care and the specialist. And about half of our specialist visits, particularly to the cognitive specialist versus the procedural specialist, are managed virtually. And when they're not managed virtually, then at least it gives the opportunity for the specialist to say the PCP, okay, before I see this patient, I need you to get this diagnostic test because otherwise I'm going to see him and waste their time and send him for the diagnostic test. So there is, and what the specialist like about it, it particularly when there's a shortage of specialists is that, first of all, the specialist will tell you lots of nightmares where people got at the end of the line. So they called and they couldn't, you couldn't get in and see the specialist for three or four weeks. And the specialist then sees the patient says, oh my gosh, if I only known. And we have pictures, we have a case, one of those, one case where a young man walked in with a dark finger and had his melanoma resected in less than a week. That would have never happened in Chicago. I mean, you can't get in and see a dermatologist for six months, but the dermatologist saw that finger and said, my gosh, it looks like a melanoma. He got that patient in, he got him in to see the surgeon, he got it resected. And the other thing the specialist like about it is that it's less resource intensive for them. And it also, there's a hundred percent show rate with any consult, right? So I don't have to worry about the patient not showing up. I've got the consult, the time is convenient for me is I can access and respond, our specialist are required to respond in less than 48 hours. So it's much more timely for us. So there is a rational way to do it. The problem with the consult is that most payers don't reimburse for it and we're under fee for service system. So you're seeing the more progressive models like you're going, if you go out to Utah and within our mountain, you're seeing that they are moving towards capitating their specialist. There was a movement towards that back in the 80s and 90s. We moved away from that as we moved away from managed care. Now there's some interest in moving back. So that's really the issue of the specialist. In terms of the workforce is that we train the workforce. So if you're an FQC and interested in Chicago, don't wait for them to come with a certificate. You basically hire people from the community and you start with them becoming the receptionist of the medical assistant to the lab tech and eventually you train them. So our ACO has a six month training program for our care coordinators, our community health workers and they have to work and earn the salary. So they are given off two half days a month to come to the courses. We're really training them and teaching them and they get a certificate at the end. So it's really, if we're going to deal with the workforce issue, we have to be willing to invest and train that workforce. Don't expect somebody else to train them and they come to us. In terms of the one stop shop, that's the whole story of FQC's, right? All story of FQC's is that they have behavioral health, they have primary care, they have dental, many of them have optometry and so, and so, and people do want that. I mean, when there are surveys out, when we survey patients, it's often they are looking for that wide variety and they don't want to have to be traveling in multiple places. So I think that one stop shop certainly resonates with a lot of our patients and then the last issue is primary care is, that is again, exactly the point in terms of primary care cap. So what happens right now is that most primary care practices have gone to open access. So they'll have a certain number of slots that they reserve for open access. Well, guess what? If you happen to call in the first hour, then you've got a slot and if you don't make it in the first hour, there's no more slots or maybe there's a slot with somebody else. We have to rationalize the system to sort of say, okay, if the ideal thing is that we want to reserve our primary care spots and reserve, so you can see your own primary care provider, then I had to reserve those slots by giving them to people that actually had to be seen face-to-face. But if my business model is that I got to make sure all those slots are full, I'm going to give them to wherever calls comes in. So what you'll see a lot of them do is they will, the first people to call in, they're just given the slots or aren't even talking to a nurse. And then those that can't get seen may or may not get to talk to a nurse or just kind of give an appointment for two weeks from now. So we have to rationalize the way that we're providing access and we're using our workforce, which we don't do under fee-for-service. Okay, Rick Dooley. Great, thanks so much. That was actually pretty fascinating and sort of highlighted a lot of the issues that I think Vermont sort of struggled with. I actually have two questions. The first is early on we talked about, or you talked about provider taking risk and we always have a concern with primary care providers taking risk because we're sort of on the, just on the line of financial viability as it is and the idea of a risk-based system when we control so little of the cost. I know we can help reduce hospital readmission, certainly transitions of care, but we're not big drivers in the costly overall system. And so if we have big parts of the system that are so, so expensive that we can't impact, it's difficult to have sort of some of that risk assumed by the primary care providers. And I also, in that same vein when it comes to setting the PMPM, if I recall from your slides, it looked like you took sort of the total cost of care, divided it by the number of members and that's sort of the PMPM or something similar to that. Does that, is that based on practice or on practice type or is that across the system? So we have, we have FQHCs, independent providers and hospital employed primary care providers who have very different sort of pay scales. And would this sort of bake those same things in those same variants in or would this be sort of across the board? It is what it is regardless of who the provider is. That's question one. That's a big one. Okay. So let me deal with first of all, shared risk arrangement, total cost of care, individual providers need to form an integrated delivery system and share that risk. And as you saw in our situation, it also is shared with health systems. So I'm not, I'm not suggesting that you put individual providers at a undue risk that potentially could push them into bankruptcy. We're not helping our health system by doing that. On the other hand, you have to have some accountability in terms of, and so we've kind of gone from one, we go from one extreme where the health system makes all the risk and the providers don't feel any of that accountability. That's not good either. So it's not, it's not easy, but coming up with, hey, what's an unreasonable amount of risk and accountability, but also what's the amount of reward that goes with that? In terms of primary care cap, a lot of the models we've built are with FQHCs. FQHCs has something very unique in federal law, which says that if they move to a capital alternative payment methodology, is that at the end of the day, is that they have to have received as much revenue as they would have under fee for service PPS. It's specific to them and it's specific to rural health clinics. I can tell you the experience in the markets that have moved towards is that that hasn't, they haven't had to pull that trigger, but that is there. In terms of primary care providers that are not, is that the trick to this is actually is being saying, well, what happens if it can't be a single rate? There has to be a risk adjusted rate and there's not great risk adjustment methodologies you realize most of it is based on disease burden, but there has to be, we have to do the best we can in terms of that. If the primary care provider is a large enough group, there's enough patient population that like an FQHC, there's enough primary care providers, I mean, excuse me, primary care patients that the average risk that population doesn't change from year to year significantly, you could put that into the model if you want. And so we're working with or about to start to work with an ACO down in Massachusetts that wants to move their providers and they are not an FQHC too. And so Massachusetts has a risk stratification algorithm that includes social drivers of health that is built into their district program. So we're gonna be looking at how we do risk adjust. But there is some risk to that. Again, you have to set, and any time you take downside risk is you have to set a corridor beyond which you're saying, I'm no longer going to put these providers at risk beyond that corridor because we don't wanna push them out of business. All right, great. And then my second question is, I think when you're talking about committee structures it sounded like you said that each practice had a provider champion for that practice on the committee for the ACO. Is that correct? We have a sort of different representative model with our current ACO. And so we have, for example, there are two seats on the board for independent, that represent independent practices, but we have considerably more than two independent practices across the state. And so it's difficult to get accurate representation. But so in your model, every practice has a seat at the board. No, so every practice has a seat on the board but that's not what I showed you was the clinical. There's a separate clinical committee that reports up to the board. What we wanted was, we didn't want each of our FQCs to have to start with a blank board and sort of saying, how am I gonna deal with transition to care? How am I gonna deal with frequent utilization? How am I gonna deal with the SMI population? So we want to share our experience. So what happens at that clinical is the provider champion is actually the one that ultimately sort of says, as a general approach, this is how we're gonna deal with that issue. And then it's my responsibility to customize that and make it work in my particular practice. So there are the, and because they helped it, it's not being opposed upon them. You know what it's like, is that somebody comes in and imposes a model on you and you didn't have any say in to create it is you're gonna resist it. So this really gets their buy-in because they have a, and it's all based on data because those models are coming out because we're looking at our utilization and cost and quality data and making intelligent decisions based on what we're seeing. All right. No, it's great. It's very provider centered. It's great. Sure. Thank you, Rick. Okay, Mort Wasserman. Hi, I have two questions, sorry. First one, as you've already shown a lot of awareness, Vermont's a very rural state where either the first or the second most rural state in the country depending on by the definition of proportion of the population that lives in a rural area in Vermont, it's 60%. And so since it seems like you have experience with both urban, your company and rural areas, I'd like to either comment on and compare the experience in urban areas or how has the rural experience been different and what have been the special challenges in the rural areas and how have they been dealt with? Yeah, so the rural and even in states like Illinois, basically there's a lot of rural part, a lot of FQC's are serving rural communities. It's just that there's this concentration up in Cook County and the Collar Counties. But a good experience where again, worked on this primary care was Washington State, which there is Seattle and Tacoma, but you get outside of it and it's actually very rural. It probably looks a lot like Vermont, right? And so I think, as I mentioned before, the rural areas have a harder time attracting primary care providers. And so that really is a challenge. So they kind of embrace this because they view this as a way to deal with their issue of the fact that I can now make sure I'm intelligently using my primary care providers and taking a care team approach. But they certainly have that issue. They also have issues just in terms of just patient population density. They don't have the same size panels that a urban FQC does. And there is some value to scale, right? In terms of, hey, I have a fixed cost and now I can spread it over a large number of patients. And so they struggle, I think, a bit from that perspective as well. And then the other thing they really struggle with too is in some of those areas, is access to behavioral health specialists or access even to other medical specialists that they just don't have the same access that you have in an urban area. So they're really forced, and you have to admire a primary care doc who's out in a really rural area because he's asked, he's really forced to sort of saying, it's you or nothing in many situations. So, all right, thanks. My second question has to do with people who aren't old and chronically ill. So this experience is all like people with diabetes and hypertension and congestive heart failure. I'm a retired pediatrician. My patients were totally different. They faced the whole noise about adverse childhood experiences. Well, they happen every day. And those kids are not that expensive right now. They're cheap, but they're gonna be very expensive in 10, 15 and 20 years. So how do you build that into the model? Because 20% of our population almost, and a great majority of the Medicaid population are kids. Right, thanks. And we often don't scream for those aces, right? Because if we find out, what are we gonna do with it? Right, because we don't have capacity. So are we going to build, we're gonna have to build again a collaborative care model that deals with kids that have those adverse childhood experiences and sort of say, okay, what is it? How are we gonna deal with them? But it can't always be with a behavioral clinician or a pediatrician, right? So I think building those models, I think we're still waiting for those models and you obviously have more experience than I do. But you're absolutely right, is that. And I think the other place though in terms of primary care cap where you do see it for pediatrics is again, just the low acuity conditions that result in ED visits, right? And so if we can improve access to care, because a lot of it can still be dealt with by a nurse or by a quick transfer to a telehealth visit with a safe, be more convenient for patients. And some of that is they start to learn too, right? And pretty soon they start to learn like, hey, you know, I can do more to self-manage. Instead of, what happens when you go to the emergency room is they don't tell you why you shouldn't have been here, right? They treat you and they tell you if you don't get better, come back. And then we wonder why patients come back. You know, we just taught them to come back for things that they never did to be there in the first place. So it's, and then we blame the patient. Thanks. Thank you, Mort. Richard Slusky. Hi, Dr. Jones. Richard Slusky, I'm a former hospital CEO and also worked with the Green Mound Care Board on the development of the all payer model. So my question, I may have missed the point, but my question to you is in the current organization you're with, is this an all payer model or is it strictly a Medicaid MCO at this point? Yeah, I wish. So we started our own Medicare Advantage Plan. Talk about bad timing. We started just before the pandemic, January of 2020. We are going to move into the direct contracting model for our Medicare patients. But when I, back at the FQC, I was at where we're taking the same kind of risk as we did it for commercial Medicare and Medicaid. That's right, but in your practice, you did all pay. Yeah, yeah, which really makes a difference, yeah. Right, so my question in Vermont, as you know, it's an all payer model. Exactly. And one of the things I think, I'm wondering what your thoughts are about the hospitals participating in your network and in a shared savings, you're still embedded in fee for service mostly. And so I'm wondering if you thought about moving the hospitals to global budgets based on their past revenues and how do you think that might work? Yeah, I did a little bit of work with region A in Maryland as I have some familiarity with their experience. I think in a rural area like Vermont that works, it probably doesn't work that well in Chicago where there's so much transfer of people back and forth. I think one thing we're looking at in the hospitals to start to bed within our shared savings is using some episodes for certain procedures and getting them focused on, okay, how can it be more efficient in managing this particular knee replacements or hip replacements or whatever. So we are looking at that. But again, for the hospital system to engage them is that they have significant, they've employed a primary care practice. And so getting them involved with that is a way to kind of engage them as well. But it's a shared risk arrangement where they have some skin in the game if they don't do well as well. Okay, thank you. Okay, Dale Hackett, I see your hand is raised again. Yes, he's so good. I really wanna ask him this question because I have a feeling that he will have an answer. So when it comes to pediatrics, like I was an expensive child. I was born, there was a stroke of mayorscipio lobe and so I was born legally blind. I have vision, I was just my field of vision, I'm legally blind. What would happen is I would end up in the hospital or at the hospital, there'd be running tests because this was happening, that was happening. I'm a child, all I know is I don't feel good. And my next door neighbor was my low vision specialist and I would be talking to him while I was working in the garden and he would say, come on in, let's check your vision. And I was like, that don't make sense to me. But what I learned is he would fix my vision and those symptoms would go away, all things are connected. Do you find that, what I'm trying to get at I think is really important. How often do you see patients come in and with this model, can you better manage where you know the symptom is really something else? Like in my case, it was vision because you can treat the symptoms all you want. You're missing the diagnosis, you're missing the natural treatment that'll make a difference. Hopefully you understand that. Yeah, so a good example that really is behavioral health comorbidity. So you'll see the patients, you'll see patients that are coming in repeatedly for chest pain and they're really having panic attacks and they've now had their chest pain worked up and they don't have coronary disease and so as a primary care provider, you often get frustrated because they keep going back to the emergency room and if this one in the emergency room figures out that they'll go to a different emergency room. So until we deal with the underlying issue for them which is not so much your chest pain but their panic attacks and stop blaming the patient they're gonna continue to access the system. And so I think there's a big overlay of behavioral health that we don't do a very good job as primary care buyers or an adequate job in terms of detecting what really the underlying issue is. So I don't know if that gets to your question. I'm not sure that, I mean, that's just good practice of medicine and I'm not sure that this is better under a model to the extent that an FQC has behavioral health there that when I'm seeing that patient and I'm sort of sensing that they have a panic attack that I can open the door and do a warm handoff to that behavioral health clinician who can at least meet the patient versus what we do and what otherwise happens is we'll give you an appointment with a behavioral health clinician and we know the shell rate is really low. So to the extent that you again to that earlier question about a one stop shop you can whether it's a care manager whether it's a behavioral health is that you can meet that person and start to build a relationship they're much more likely to come back and that you really need that behavioral health clinician to help us really get to the underlying cause of what's causing those panic attacks and helping to deal with them. Okay, is there any other public comment? I see no hands raised. So at this time I'm gonna thank you very much. Art and Caitlin, it was a fascinating conversation and I think we learned a lot and it's fascinating to see the passion that you have for your work, Dr. Jones, so. Well, thanks. Well, we certainly admire the work that's going on in Vermont and we know it's not easy. It's easy just to stay with the old system and you guys have bucked the old system and really tried to be innovative and so we certainly admire from a distance the work you're doing as well. Thank you so much. Okay, at this point in the agenda we're gonna move towards a discussion of the guidance for executive compensation at accountable care organizations and I'm gonna turn it back over to Russ McCracken. Russ. Great, thank you, Chair Mullen. I'm here at this point to present a proposed interpretive guidance regarding executive compensation structure under the ACO oversight rule. The draft of the guidance and I have some slides I should be presenting those. The draft of the guidance itself was circulated to the board and post on the website and also provided to OneCare of Vermont and the HCA in advance of this meeting. As just a bit of background, as part of the fiscal year 21 budget oversight and certification process for OneCare, the board asked legal in both the budget order and the certification memo to explore some different options for ACO executive compensation structure and putting some additional requirements around that. One of the options that was looked at was a broader revision of rule five, the ACO oversight rule to add in additional requirements regarding executive compensation structure. That broader revision is delayed or postponed to a bit of a later date, largely out of concern or the thought that there may be some additional changes forthcoming to the ACO oversight rule potentially to address the regulation of Medicare only, only ACOs, the direct contracting entities or ACOs with a limited footprint in Vermont, some uncertainty around the future of the all payer model and a general concern that we didn't want to go through a rulemaking process and complete a rulemaking process with interim changes only to turn around and immediately start a new rulemaking process for the changes to the same rule. So with that in mind, we're proposing interpretive guidance regarding the requirements for executive compensation under and within the scope of the existing rule five. So under rule five, two or three A, the rule requires that an ACO must have a leadership and management structure that aligns with and supports the ACO's efforts to improve quality of care, improve population health and reduce the rate of growth in healthcare expenditures. And the guidance that we've proposed says that to comply with that section five, two or three A of the rule, an ACO must structure its executive compensation to achieve specific and measurable goals that support the ACO's efforts to reduce cost growth or improve the quality and overall care of enrollees or both. And as we kind of lay out in the guidance, as we lay out in the guidance document, the executive compensation is a necessary part of the ACO leadership and management structure. And this guidance is consistent with and advances healthcare reform principles in 18VSA 93.71, specifically principles that the healthcare system must be transparent in design, efficient in operation and accountable to the people it serves and that Vermont's healthcare system must include mechanisms for containing all system costs and eliminating unnecessary expenditures, including by reducing administrative costs and reducing costs that do not contribute to efficient high quality health services or improve health outcomes. The guidance that we've proposed would be, is an interpretation of how ACO's comply with five, two or three A, which is a certification requirement. So in the annual eligibility verification submitted by an ACO, ACO would explain how their executive compensation structure complies with five, two or three A as we've interpreted it in this guidance. And I will pause there and open up for questions or comments or concerns. Are there questions from the board? I had one question when I was reading this is to, what is the consequence if the annual eligibility verification doesn't verify the ACO meets the requirements of section five, two or three A? Yeah, complying with or continuing to comply with five, two or three A as a requirement for continued annual certification of an ACO. And so if an ACO is not able to comply with it or it doesn't establish why they would comply with it, it becomes an issue with their continued certification. This is Robin, I just wanted to jump in. I haven't looked at the rule all that recently, but the rule does outline sort of enforcement provisions of various sorts. So I think like any other part of the certification, we as a board could determine the appropriate enforcement mechanism. Thanks, yeah, this is Micah. Go ahead Micah. Just to chime in too, yeah, there's a section on the board's ability to take action on certification. So to suspend or revoke certification of an ACO, which requires advanced written notice and an opportunity for hearing. But I think the primary corrective tool the board has is to require a corrective action plan. So if the board felt that an ACO was not complying with this, there could be a corrective action plan that the ACO would submit to come into compliance over a certain period of time. And so that. Okay, other questions or comments from the board? Is there any type of action required for interpretive guidance? To approve the interpretive guidance? Yes. Only that the board, only that the board vote to approve it. It doesn't go through a separate rulemaking process. Okay, so it's a simple vote one time by the board. Yes. And you're looking for that today? I have some proposed motion language here if the board prepared to do that today. Maybe you should just show that language before we open it up to public comment so people will have access to all of today's information. Can I ask a quick question? Go ahead Robin. Was it noticed for a vote today? That's a good question. I didn't notice it being noticed in the agenda but that doesn't mean that it wasn't noticed in the press release. So I'm not sure if maybe Abigail knows or. Abigail, do you know the answer to that question? It was not noticed in the press release or the agenda today. So I think that probably the best thing to do would be to postpone the vote until next week unless there's some type of urgency that I'm not aware of. Ah, there's not. Okay. So at this point I'm going to open it up for public comment and I see that Walter Carpenter has his hand raised. Hey Kevin, thanks. I'm just curious. Who sets the ACO CEO salaries? That would be their board of managers. Because you've got a $19 million payroll for the ACO so I'm just curious who sets all that. Does the board approve it or do they or do you even have a say in it? The board has oversight over their budget if you mean by this board but it's the board of managers to make the internal decisions. Is there other public comment or questions? Hearing none, we'll come back to this discussion next week. And if Abigail, if you could open up a period of public comment on the website on this, that would be great. And let's have that public comment in by Monday so that we will have time to review any. We'll always accept it past that but it is just would be good if the board had time to review it. Okay, is there any old business to come before the board? Hearing none, is there any new business to come before the board? Hearing none, is there a motion to adjourn? So moved. Second. It's been moved by Maureen and seconded by Jessica to adjourn. All those in favor signify by saying aye. Aye. Those opposed signify by saying nay. Thank you everyone and have a great rest of the day. Bye-bye. Bye-bye.