 Okay, we are live and on YouTube. Good morning. This is the House Health Care Committee and it's Thursday, January 28th. Before we get started with our witnesses this morning, we have a couple brief introductions. A number of our committee members have students working with them as interns and we are wanting to just give them an opportunity to introduce them to the committee and to others before we get started. So I'll start with our representative Donna here and then represent Goldman. I think you each have an intern to introduce. Thank you very much. I've been working for the past month and looking forward to the rest of the session with Rachel Best from UVM and I'll give her a minute to tell us where she's from and what you're studying in school and all that sort of brief intro. Hi, I'm Rachel. I'm a junior at the University of Vermont studying political science and I'm also minoring in history and health and society and I'm very excited to be working for the Vermont State Legislator. It's all very exciting to me and I am originally from Westchester, New York, but yeah I'm loving Vermont and everything so yeah I'm happy to be here. Good, but welcome and welcome to your work with representing Donna Hew and the House Health Committee. Can you represent Goldman? So I have the pleasure of introducing Alexis Drown also a UVM student 24 grad. She's been doing great work supporting me particularly technologically which has been a great challenge and doing research as well. So Alexis a brief introduction. Yeah this has been super exciting getting to work with Representative Goldman. I am from UVM. I graduate 24. I'm a freshman. I'm majoring in both psychology and political science with a minor in Spanish. I'm from Vermont. I'm from Milton, Vermont which is only like 30 minutes away I'm assuming you all know. Yeah this has been a super interesting experience. I'm excited to kind of get some hands-on political science work. So yeah well thank you. It's a great place for you to be and welcome. An unusual way to begin but with joining the Zoom legislature the 19 or 2019 2021 legislature. So with that I'm going to ask welcome interns but I'm going to ask you to go off video screen if you would please because it's easier for me as the chair to track who's who's in the meeting and who has questions etc. We're going to begin this morning we're going to continue our testimony about the call payer model and we'll get the name right shortly it's a lot longer than that but yesterday we were hearing we heard both from the Green Mountain Care Board about their work generally and then also from Ena Backus who gave us a an overview of a good deal of the history of Vermont health care reform and I would recommend those if for our interns for your interns if you hadn't had a chance to be with us yesterday you might want to go back and now you can on YouTube you can watch Ena's presentation it was it was very useful to I think to have us have that background. So today we we cut Ena's presentation short a little bit but we're going to start with Ena who is the director of health care reform for the state of Vermont to complete her testimony around the all-payer model then we will take a break and we will then hear from Elena Barabee from the Green Mountain Care Board about their role and and the all-payer model and take another break and then we'll come back and Ena will continue to review with us some of the work that the agency human services has undertaken in also reviewing and which some refer to as the reboot issues around the all-payer model so with that I think I'm going to turn to Colleen just to make sure I'm not forgetting something else that I should be doing before we go hearing from our witnesses but I think I think we're good okay so again good morning and welcome I'm going to turn oh and for committee members Elizabeth will be joining us Elizabeth Burroughs she had a family Aaron that was necessary and she let me know she'll join us shortly and I believe representative Cordes is going to run down the hall to natural resources at some point this morning to present a bill but we'll go and be back yes just don't run too fast and we'll look for your return okay so without this turn to rip let's turn to Inabakis from the agency human services director of health care reform and again probably just for the purposes if you just you know just briefly introduce yourself or quote our zoom record good morning for the record my name is Inabakis I am the director of health care reform at the agency of human services thank you for having me back today I will share my screen again hopefully you can all easily see can I apologize I apologize you know I failed to introduce Sarah Berry from one care who is also on screen with us this morning perhaps we could go just so people could have Sarah introduce herself sharing in a moment yeah good morning I'm Sarah Berry I'm the chief operating officer for one care Vermont thank you for joining me this morning great thank you thank you for joining us I appreciate you being here okay let's let's continue then thank you and thank you for the reminder calling oops it's really nice to have the opportunity to follow up the next day with the committee and to to continue our our conversation about health care reform at the different problems that our health care system confronts and the different ways that we can address those problems through reform initiatives and so thank you yesterday we talked about the the problems that our system is confronting one of those problems that I believe we all appreciate is the rate of cost growth in our health care system and I think we also can appreciate that the quality and experience of care in certain instances for persons that are experiencing and utilizing health care services across the care continuum can be improved and certainly outcomes for Vermonters can be improved too with respect to addressing health care spending growth we talked yesterday also about the predominant way that the health care system has been reimbursed for health care services in the United States it remains the predominant reimbursement methodology for the health care system however there is emphasis bipartisan emphasis federal and state and health policy leaders emphasizing that if we could move away from a fee for service reimbursement system where each and every service that is delivered is is paid for regardless of that of the quality or the outcomes that that we may be better positioned to both control the rate of growth in health care spending as well as to improve the quality of care that is delivered and the and the complement of services delivered to most appropriately need meet the needs of both of Vermonters and any anyone seeking care as well as to do so in a more efficient in a more efficient way and the through the all pair model agreement and which is our state and federal agreement which I'll delve into more in the next slide we are able to move towards setting a budget for the health care system that is participating in this model instead of paying for each and every service performed regardless of the outcomes and and clearly tying that budget with a measurement framework and an accountability framework to the quality of care and ultimately improved health outcomes for Vermonters we call this reform initiative Vermont's all-payer accountable care organization model agreement the agreement that we have to pay differently is is one where each major payer group that covers Vermonters in our state Medicare covering older Vermonters Medicaid covering traditionally low-income Vermonters and commercial insurance covering Vermonters who are employed Vermonters self-employed Vermonters who are individually purchasing commercial insurance coverage this agreement in place allows for those major payer groups who are participating to specifically pay an accountable care organization differently than the traditional fee for service reimbursement methodology and the agreement brings Medicare into the space of paying differently in Vermont an alignment with the other major payer groups without an agreement of this kind Medicare would continue to pay fee for service in Vermont just as it does predominantly in in every other state and has done for a very long time and I'll emphasize again that Medicare in in this model agreement and and we'll talk after after after I I review again what the model agreement is as I'm doing now Elena is going to dive more deeply into the responsibilities that the Green Mountain Care Board has for monitoring in the agreement and for doing some regulation in this agreement and then I'll come back to the implementation improvement plan where we have we have put forth recommendations for how we can perform better in the agreement and I'll say that moving our Medicare payer partner more aggressively away from fee for service is very much a recommendation that we put forth and that we are working towards however I think it's very important to acknowledge that Vermont and the way that Medicare is paying our ACO differently is today even though it's not as differently as we would like to see is really a major step in the right direction and excuse me Medicare is only paying this way in in one other state in the whole United States to one other ACO so it really is a innovative model with Medicare participating even though we have a lot that we've learned from how our Medicaid program is operating and even though we can do better I don't want to under emphasize that we are innovating with our federal partner today the agreement that Vermont has with the federal government holds the state accountable for curbing healthcare cost growth and improving quality of care population health outcomes and Vermont is also accountable in this agreement for ensuring that the participation in the model reaches a scale over time and that is a truly statewide model the Center for Medicare and Medicaid Innovation was very interested in working with Vermont to apply a model that could be statewide and consistent across our our population not only for the consistency with the an alignment of the changed incentives but also to demonstrate that there can be a consistent approach for excuse me for a state the the agreement as chair Lippert noted it has a long title the the long title of the agreement is the Vermont all-payer accountable care organization model agreement and I frequently come back to that title when I think about the key element of elements and elements of of our our federal state partnership and it certainly is a very central element is that the accountable care organization is the entity or entities that can accept through this agreement the the alternative to fee for service payment accountable care organizations are a network of providers who are accountable for the cost and quality of care for a defined population there are a couple of key opportunities with accountable care organizations that are beneficial when paying differently the first of course is we are aiming for more integrated care across the care continuum in our state we we have a goal for there to be seamless delivery of care across the variety of settings where Vermonters need and want to receive services and with an accountable care organization that creates a a organizing influence and a formal network of diverse providers that are actually choosing and agreeing that they are working together to be accountable for the care and quality of a defined population so in of itself an accountable care organization is a vehicle for care coordination and integration of different services additionally the accountable care organization allows providers to to share in any savings together that they may achieve through offering care in this different manner through better coordination and and through innovating and transforming the delivery of care for their patients so again our model our model invites alternative payment methodologies so alternatives to fee for service and and it includes Medicare in paying differently and that different payment is is directed at an accountable care organization and the agreement is agnostic to how many accountable care organizations could participate in vermont we have one active accountable care organization which is one care vermont and you will hear more from from them if you haven't already you will hear more from one care vermont about who they are and and and what they do but they are a key partner in this agreement not a signatory to the agreement but a key partner in implementing the agreement because they are the single accountable care organization in vermont we have an agreement with cms acos and payers choose to work together to to participate in the agreement first of all and and then work together to develop agreements within that network of providers and then that network of providers the acos and the providers who want to work together then develop provider led agreements between the aco and the and the and its participants our agreement has key targets for annual growth and at the end of the agreement which is four excuse me five performance years we are in performance year four now the the target growth rate is that healthcare spending in vermont for the services that are included in the in the agreement and that is that's a that's another place where we can we can elaborate further those services are roughly equivalent to those services that medicare covers in its physician and hospital program not all services are subject to the total cost of care target for spending and some key examples of services that are not subject to that target as pharmacy services and pharmacy is not subject pharmacy spending is not subject to this to this agreement target the the target is 3.5 percent uh up to 4.3 percent medicare has a separate growth target because medicare is participating in this agreement and also medicare wants to see healthcare spending growth uh uh moderate in our state they also want to test whether um by moderating through this model in the state of vermont they can apply this model more broadly within the united states the medicare growth target is uh 0.2 percentage points below national projections the agreement requires that there be alignment of payer programs across the participating payers and the agreement requires that they are again is a scale of participation um that is the preponderance of the vermont population be included in fee for service alternative payment models that are qualifying a co scale target initiatives through this agreement we also commit in the agreement to improve access to primary care to reduce deaths due to suicide and drug overdose and to reduce the prevalence and morbidity of chronic disease i'll take a moment to describe i i reference the key partners in implementing this agreement there are three signatories to the all payer model agreement from the state of vermont and the agreement is something that the state of vermont uh uh signs on to with the center for medicare and medicare innovation which is a part of the center for medicare and medicare services the ms the green mountain care board and you'll hear very soon now from elena and so i won't spend long here because she will describe to you the green mountain care board's particular role in the agreement but the green mountain care board is a key uh signatory both signatory and uh holds a lot of responsibility in this agreement for monitoring reporting to cmi and regulation of the system within the agreement the vermont agency of human services is also a signatory along with the governor um and the agency of human services is a part of the administration is responsible uh through the agreement and and is required to offer a medicare program of alternative payment that is consistent with the terms of the agreement uh and meets meets the requirement for the alternative payment model within the agreement and and and the agency is responsible for reporting to cmi specifically regarding uh how in a future agreement additional services across the care continuum could potentially be integrated into the targets for cost growth moderation um that is something that is not um i want to be very clear we we have the duty to propose a potential model in this in this way it does not mean that we necessarily are required to incorporate these these services into a financial target we do have to explore and and and make a proposal for what would be appropriate if if if any inclusion is appropriate the accountable care organization and in vermont again we have one accountable care organization one care vermont in in as being a partner in this agreement is responsible for contracting with payers um in these alternative fee for service models and working with its provider network to uh perform in this alternative payment model and to do so by implementing delivery system changes that would would uh help help its network to deliver care more efficiently and to improve the quality of care delivered and thereby uh we we hope to see controlled cost cost growth and moderation and finally private insurers in vermont also our key partners in the implementation of this agreement the private payer needs to have a contract with the aco to provide for this alternative payment and those and and so those private payers need to develop these contracts um with the aco in order for there to be a commercial participation in the agreement this is this is voluntary and we however we have um we certainly have work that that we can do to highlight um the the significant benefits of this type of contracting arrangement that we have seen through a Medicaid next generation aco program and i would encourage you to do a deep dive on that on that program and how it performs and what it has looked like over the last number of years um we can certainly use our experience there in our Medicaid program um to help commercial payers that may be interested in participation to understand the benefits of this alternative contracting model with a network of providers who are aligned through an accountable care organization like we said yesterday or like i said yesterday it feels like we because my family is all here with me uh as as i as i explained yesterday the all payer model agreement is a five performance year agreement and we are starting performance year four now and with that we have been able to observe three years of performance in the agreement and to see where we have areas for improvement and i talked through these four main buckets for improvement uh yesterday and and those include work at the state and federal level work at the state level to um to ensure that we are prioritizing and aligning our health care reform activities with this model work at the state level on the regulatory framework and work at this at the aco state aco in the state um to to strengthen its approach to ensure that um there is uh the opportunity for the for the best amount of participation um in this model as well as the to realize the most potential benefit um from delivery system transformation and at at this time um i think it would make sense um for Elena in her presentation to elaborate on the Green Mountain Care Board's work in monitoring and reporting in this agreement because i think that that will help to demonstrate um for you what we have what and how we've been looking at the agreement and the performance in the agreement over the last performance years and after that point then um then i think that there will be more context for me to discuss some of the recommendations that we've made for improvement okay uh thank you thank you iina um not being clear on not being sure you know what our timing would be this morning or it said we'd take a break between uh iina's presentation or follow-up presentation and hearing from Elena Barabay uh why don't we take a five minute break and uh people can get a let's see let's make it a time so let's return at 9 35 we'll take a stretch break uh we'll hear from Elena and then we'll take a longer break and we'll come back and hear from iina and entertain a broader set of questions does that work for folks so again can i remind people that when we go on a break please mute yourself and go off video let's be appreciated thank you we'll be back in five and thank you iina and i i i think that was helpful to have that recap uh some more so appreciate you taking that extra time to do that and at this point uh Elena let's turn to Elena Barabay from the Green Mountain Care Board to discuss further what the Green Mountain Care Board's involvement role is and has been with uh the all-payer model great um so while i find my slide oh it looks like i'm still disabled from sharing okay well let's fix that uh Colleen can you think that will be something that Colleen needs to help with well okay here we go okay great okay so i'll um introduce myself first i think yes please have been in this committee too too often um so Elena Barabay um director of health systems policy with the Green Mountain Care Board i've been with the board about a year and a half now before that i was in education policy tax policy i worked in academia um before that and finance even before that so i've kind of public private partnership um experience um from both sides um so i'm here to talk about the role of the Green Mountain Care Board in the all-payer model as um we've been pointing to throughout this morning's conversation thank you so much for having us um so you know the Green Mountain Care Board's role in health care reform broadly is really to serve as the regulatory body over the private health care um segment of the health care market um and with the goals of curbing health care cost growth and improving quality and population health um the board also serves as a steward of health care data and provides analytics for both public consumption and for policymakers um and this supports a transparent statewide view of cost and quality across the vermont system of care um so specifically in the all-payer model agreement um there are kind of three key you know bodies of work um that we focus on um so we serve as a kind of a proxy for medicare um in some sense and i'll talk about what that means um we you know work towards regulatory alignment so we also have some other regulatory processes such as hospital budget review um c o n insurance rate review um and so any you know opportunities we have to kind of link um those processes to the goals of the all-payer model you know it's a constantly evolving process we look for ways that we can tighten um those regulatory opportunities within our existing um authorities um and then as i mentioned before kind of the statewide health care data and analytics so we do a lot of the reporting um and analyzing kind of drivers of cost cost containment and quality um and then report that um out to the our federal partners so in our role as a as a proxy for medicare you know we establish the health care spending targets um which is the mechanism for constraining fee for service health care cost growth um in the agreement um we also have the role of recommending program design modifications to the medicare asio initiative um so in where there are opportunities to better align with other vermont health care form efforts and to kind of further the goals of um you know the vermont health care reform as stated in in staff um in terms of regulatory alignment as i mentioned you know this is not exhaustive but you know in our hospital budget review we look at um how hospitals are engaging in health care reform efforts you know are they investing in community um community health improvement programs what percentage of their revenues are fixed payments so are they actually moving away from fee for service and is that enough sufficient to kind of drive the changes we want to see um we also um are responsible for uh asio or accountable care organization budget review and certification for act 113 um so there are you know specific criteria in the statute there but as we also kind of think about the goals um of the all-payer model and how these programs kind of align or how the asio's programs align with those goals um and review their programs and their and their budget um to understand kind of their how they're contributing to those um those goals um and we also get health insurance rate review and and what our payers are doing in the commercial side of things to to kind of further our health care reform efforts if i could just interject here for a second particularly for our newer committee members act 113 which referring to was a major initiative of this committee a number of years ago prior to that the vermont care board did not have regulatory authority or over cert or certification responsibility for accountable care organizations in the state of vermont and after i believe it was a mere three or four years ago but that does seem like yeah a long time well three or four years ago but but nevertheless uh it's interesting as act 113 is referred to as just an essential piece of what we're doing uh some of us remember the period when we were trying to determine what that should include and how it should come into being uh just I think it's useful for our committee members in particular to to understand that that's part of the work that this committee undertook like you say a mere three or four years ago thank you sorry Elena but just no that's great um okay so as it pertains to the you know health care data and analytics um role you know as i mentioned before we report on our state's performance under the all-pair model agreement on cost quality population health outcomes and scale we also monitor for rationing or cherry picking so that's you know trying to serve populations that may be more financially beneficial versus those that you know really this is a vermont wide model we want to make sure that these reform efforts are helping everyone and then we also analyze patterns and utilization and cost over time and across the delivery system um so just you know to be extra clear I think Ina covered a lot of this but just to you know distill it down what are we measuring we're measuring uh five-year health care cost growth so you know while we we report out on an annual basis to our federal partners the accountability is really for the over the term of the agreement um but we we kind of check and see if we're on track and that's you know our role on that board um scale payer and provider participation so scale is you know how many uh vermonters does this model kind of touch um but it's really a measure of payer participation and provider participation and then vermonters that are included under the model are those that are covered by a payer um and have a relationship with a provider who is participating so we track and report on that as well um quality and population health outcomes I'll talk about that in more detail in just a minute but again we um kind of track and monitor our performance on quality and how that changes over time towards our three population health goals so here's a little bit more detail about these three areas um in health care cost growth you know we're we're tracking the per person spending on certain health care services which we call total cost of care or tcoc so you may see that um language in various presentations and we measure the spending growth for both the statewide all payer um growth so across commercial medicare and medicaid um you know across the state we also look at it um just for medicare so you know I think Ina talked a little bit about these targets you know is the all-payer spending on track to be less than three and a half or four point three percent over the life of the agreement and this is really to make sure that health care costs were tied to economic growth in our state um based on an analysis done a number of years ago and then you know for the medicare population is the Vermont medicare spending growing more than the national average or we don't think want us to perform below so we look at that and and compare to national average in terms of scale I think you know I talked about this it's really about you know payer participation provider participation and that is what lets us know who attributes under this model that's what we what we call when someone is you know included in this model as a Vermont but we also kind of assess aco programs for alignment but also to determine if their scale target qualifying so that happens through our aco oversight process um but has implications for our reporting under the all-payer model um and as well as you know knowing which providers are participating also happens through our aco oversight process um in which are participating in qualified programs um and in terms of quality and population health so you know I think Ina covered this but you know we have these three population health measures to um or goals to improve access to primary care to reduce death, suicide and drug overdose and to reduce the prevalence and morbidity of chronic disease and so you know there are a number of population health measures that we track we also track 22 quality measures that are then broken out into two kind of buckets health delivery system quality targets and process milestones and so you know together this framework should allow us to understand if the pieces um are you know if we're doing the doing the things we need to do to really achieve those population health outcomes and so we look at this again on an annual basis um and determine whether or not we are on track or we're making progress um or if you know there are areas of opportunity so in terms of all payer scale um you know I think Ina mentioned before these are you know challenging targets I think there are populations included um you know in the in those goals that we know that we have little um influence over um you know that said we have made significant progress over the last couple years but there is still room to grow um and so this is in our all-payer approach so what we can see if we break this down by payer type is that you know we've seen significant progress in Medicaid um Medicare you know has grown but you know there's still work to do and I think Ina talked about um kind of thinking about how we can make those the payment program in Medicare more attractive and more like the Medicaid program um and then in the commercial sector you know there's there's definitely room to grow um you know our fully insured population is growing but you know our self funded population can see some improvement in terms of the Medicare scale you know I think it's reflected in the all-payer breakdown they showed you but you know there is opportunity there as well um so just to kind of ground you know what we're talking about and we're talking about all-payer modeled cost growth and total cost of care relative to how we think about healthcare spending in the state um you know we have on the left is our total Vermont resident spend on healthcare it's um six point almost six point five billion right um and our all-payer model total cost of care services comprise about half of that um you know so I think we have to you know be real about what you know how much we expect to move the needle on healthcare with this approach and then our ACO or our one ACO comprises 10 percent um as of 2019 so this may have gone up a bit since then but um you know 2019 was 10 percent of total spending on behalf of Vermont residents and this kind of shows you we may have seen this slide before but you know there's different costs of providing care to certain populations so while we may have you know more or about this you know Medicaid Medicare beneficiaries Medicare um costs a lot more per person than say Medicaid or commercial in terms of how we track these um healthcare expenditures over time and I think you know it sounds like we now have some experience on the committee on you know in terms of claims and coding but I just wanted to kind of um bring this slide forward again I think Susan may have and Kevin may have talked about it before but it takes a really long time um it's frustrating but to get to get accurate data because we are relying on claims data and it takes claims a significant amount of time to kind of be incurred to be paid you know for payers to clean and scrub that data for um our contractors to clean and scrub that data and for it to really become final and um before it comes to the board for analysis so you know this gives you an idea of patients incurred claims in 2020 um you know the first three months in 2021 you know they're still kind of paying and adjusting claims and that can sometimes that's three months run out sometimes six months run out you know for quality for example we'll prolong this even further and then there's a significant you know there's time needed to kind of process that data um so you know we may be in in year four of the model but the data that we have to look at and analyze is really year one we're starting to get year two and you know before we have two points in time it's really hard to kind of make um to generate some meaningful insight so you know as we as we generate more meaningful insights and get access to our data we're happy to kind of come back and report on what we're seeing there and this is another example of kind of claims incurred and and and how they're paid and how it really is a is a um link process um you know and I think just this is kind of a summary of all the reporting um that we do and I think you know GMCB leads some of this but there are some reports that AHS also um kind of takes initiative on you know the public health system accountability framework um and then the plan to integrate Medicaid mental health um services and you know social services into the um total cost of care targets um so you know but we work together on a lot of these reports um to make sure that we're we're getting all of the pieces um and and really telling a coordinated story so you know total cost of care quarterly reporting happens beginning of 2019 some of these reports you can find already on our website of um you know our annual differential um payer report so how are different payers contributing to the total cost of care um and is the ACO you know changing the cost shift um if you will um and the first annual scale target report and I think we have a couple years of this report now um we have one year of annual total cost of care so far one year quality but we expect um the second year to come out shortly um and then you know a proposal for a subsequent agreement is also included as a requirement in this um all payer model agreement and that is due at the end of 2021 uh so that is another important last so I'll pause there for any questions well I have a couple questions if I can just dive in and then I see there's there'll be some others um well first of all we're in year um let's take the questions uh slide down so I can see members if we can do that that'd be great good thank you um so we're in year four am I right yes we're entering year four we're entering year entering year four or entered yes yeah um and just what you're just pointing out the data lags behind for reasons that make a fair amount of sense but I guess one question and maybe I tap into your prior experience before being on the green mountain care board staff is the lag time uh within the lag time in terms of payments closing that out scrubbing the data getting the data finally to the green mountain care board so the green mountain care board can actually use the data is that are there any national standards for what what's what's what's the best practice in terms of getting data from the point of origin to the point of being able to use the data because it seems like it seems like a long process and then it then subsequently the question is it the data becomes really retrospective rather than being primarily able to be used for directing or redirecting any changes by the time we have the data several more years of participation will have gone by right I think that's a very good question I think you know to answer the first part of your question these three and six month um claims run out periods is what we call them in healthcare is is very standard you know I think it's just a a factor of the business process of the healthcare system and how we process claims and the coding and in our payer processes around that um you know so I think we are we are following those standards to make sure that we have the most accurate data so we're not we're not following outside of no national standards it just seems unfortunately right for everyone yes and I but I think we share your frustration about time you know you know it's hard to make decisions when the data are so retrospective and adapt quickly um and I think you know if there are other opportunities outside of claims to generate insights you know that's where maybe um we can we can explore okay uh and I'm going to indulge myself with a couple more quick questions and Comet and then we'll turn to other questions from members but we are also in the midst of a pandemic uh I think at one point I remember early on before the pandemic there was some consider we were reviewing some of this and I said well some of this assumes a um I don't want to say natural but a more or less standard progression of healthcare cause it doesn't uh there's some provision for if there are extraordinary circumstances and I think one might say accurately that we are in the midst of a more than extraordinary circumstance uh how has that how is that impacting our ability to measure uh the progress on this model and have you has the Greenmount Care Board or the agency human services address that with our federal partners and etc yes so I'll answer this and I can feel free to add um since this is a coordinated question but it will become it is a significant challenge to measure kind of the impact of this model on on healthcare cost growth over time I think anecdotally we expect you know the pandemic to reduce healthcare expenditures in 20 and in 21 so you know while we don't have the final data you know what we've seen so far kind of from our preliminary um interviews is that this cost will not be the same and it's really hard to understand you know what's a function of the pandemic versus what's a function of um delivery systems so I think we have had those conversations with our federal partners and they're very aware of this and we have some letters from earlier this summer um where we expressed concern um with you know being held accountable for you know a situation where we it's really hard you know our providers are focusing on the pandemic and they need to be right and so they may not be you know as engaged as they otherwise would be in some of these longer term and still very important initiatives so um they're working with us and you know I think you know we'll still be in in good shape but I don't know that we will have the kind of analytic insights about whether and if and how this model is is working if you will so that that will be a challenge but nevertheless it's on the whole makes sense to continue moving forward despite what is clearly a major unexpected anomaly in terms of the healthcare system in Vermont and nationally I guess I'm saying that and asking that as a question yeah I mean I think you know we we still need healthcare reform we still need to pay for care differently we still need to invest in prevention I think those kinds of those kinds of insights are still relevant and we still need to pursue them um but I think in terms of quantifying statistically how far we've moved the needle that is that is the um the hiccup I would um say for the pandemic in the all-pair model okay and perhaps you know can comment later as well okay so I'm I'm going to I apologize I don't know which hands came up first so I'm just going to use my arbitrary choice I'm going to go to Representative Houghton and then uh uh Representative Cortis Black and Goldman if you go in that order and we'll work our way through this great thank you and um thank you both of you for your testimony it's um it's interesting having walked through this a couple years in a row I feel like the presentations are getting more refined and um or really more comprehensive on what we're doing in a clear concise way so thank you for progressing with all of us on this journey with that way um so thank you for saying that Representative Houghton I was having the same reaction having watched this over a period of years thinking I think I'm finally getting more of this right yeah exactly yeah maybe we're just finally getting it and it was always very concise I don't know nobody but thank you so I have I have two questions um one and I hate to do this but I'm hoping you can go back to your presentation Alina sure it was the um question where you showed the healthcare spending they were um bar graphs I believe so while you get there I'll kind of preface why I'm asking this so um go down sorry not that far this one that one so one of the things that I think is really important for our committee and really all of the legislative body and Vermonters is is understanding what in the healthcare industry we as legislators have an impact on and we often talk about you know there's Medicaid there's self insured or RISA and where do we fall so I'm finding as we're as we're talking about scale and spending in the all pair model it's the same question and so I'm wondering if this gets to that a little bit I was hoping you could explain each bar graph again to me sure I'm happy to um so on the left the 6.5 billion so or sorry yes it's 6.5 billion it's in millions um is total Vermont residents spend on healthcare um in in this state so if you live in Vermont and you have a healthcare expenditure that's captured there so you could receive care from Dartmouth in New Hampshire but you live in Vermont you know that's in there um the all-pair model total cost of care so as we talked about is a defined set of services and I can tell you kind of what that excludes if that's helpful you know it excludes um federal you know various payers so like federal um employees um coverage um and that's fine but I think you're I think you're getting to the to what I'm trying to say which is so although the total spend is 6.5 billion really this model really only has the potential to impact 3 billion is that okay okay because of all the entities that are not covered under this as well as because payers as well as particular services so you know there are other services that may not be included you know pharmaceuticals for example are not included in the all-pair model or dentistry um so you know those would not be reflected in the cost containment strategies okay thank you and then if you do the last bar grab yes and then the last bar chart is the ACO total cost of care so that's for the programs um that are scale target qualifying under the all-pair model that the ACO pursues um and then so providers participating in that program so together that um amount of spending if you will they have they have an influence over 10 percent um of the total health care spend in ours and that is a number we would hope to grow yes that is so to get to closer to that 3. billion but we're never really going to impact the 6.5 billion right not the way the agreement is currently structured and you know there are always opportunities to think about how we evolve this model okay okay great thank you and then that's great I'm done with the presentation and then um Ina I have a question for you but you might talk about it later so if you are going to that's fine um in regards to the role each signer pays I'm pretty clear on what the ACO does and what remat care board does I'm still struggling with the role of I don't know if it's the administration if it's a you know that third piece of it and if it if you get to it when you start explaining the recommendations that's fine it can wait I think I can do a little bit now and then perhaps more with the recommendations the agreement itself has three signatories which are the green mountain care board the chair of the board the secretary of the agency of human services and the governor the agency of human services the the agreement specifies that the agency of human services must offer a Medicaid ACO program and that is our primary responsibility at the agency of human services as prescribed by the agreement with the federal government agency of human services also as Elena described to you is responsible to produce a report to assess how we are holding the ACO accountable in the state of Vermont for investing in population health initiatives and so we submitted that report in the summertime part of that strategy to hold the ACO accountable in the state of Vermont for making investments in population health activities is the regulatory apparatus of the green mountain care board in reviewing the ACO's budget to determine through its budget how it's investing that so that's another chief responsibility of the agency the of human services as prescribed by the agreement specifically the agreement also asked that the agency submit a plan to a proposal for integrating additional Medicaid services into the total cost of care and going back to Elena's bar chart the center bar describes the total cost of care and so there are key Medicaid paid services that are not incorporated into those total cost of care into the total cost of care definition or targets at this time such as home and community based services for instance again I'll emphasize well we are required to make a proposal around whether and how we incorporate additional services into a total cost of care target that does not mean that we will necessarily make that recommendation we need to explore whether it's appropriate to do so and we have also been asked by CMMI and we are working now on a timeline to align that proposal with a proposal for a subsequent agreement because a a proposal for a subsequent agreement may include significant modifications to the total cost of care targets so we need to understand what those could could potentially be before we choose or recommend rather that any additional services be subject to the spending okay thank you very much and when I'm sorry chair leopard one last quick question go ahead is there with the with the signature of the governor is there anything specific to that signature or is it just the broad support from the state okay the latter thank you great thank you thank you lorry thank you for those questions represent cordis and then represent black golden after and represent page thank you alayna and ena I have a micro question for alayna and then a macro question that could be both for alayna and ena the micro question is about I think it's slide 10 it shows the scale target beneficiaries by payer type and I was surprised at first me and it maybe it's not as small as it appeared at first but the percentage of commercial self funded so my question is do you have access or can you share with us at some point it doesn't have to be right now who the self funded insurers are or payers are in vermont and I guess I thought that the that that percentage would have been larger so I think in I would ask for you to weigh in here as well because I know in the reboot that you're kind of looking at that I mean I think we can talk about who's who's in yeah but I think we can yeah we can dig into that a little bit for you thank you and a related comment at some point and again doesn't have to be now there was a recent supreme court case in another state that changed orissa regulations around pharmaceuticals and just wondering if you think that there's potential for that to broaden into other aspects of healthcare knowing that pharmaceuticals are a huge part of the rate of increase of healthcare costs can I suggest that we take that question and and give it to also Jennifer Carby and others to bring back some comments to us at another point for some courtes sure because I think it's a broader it's an important and broader question that goes beyond the all-payer model as well is that satisfactory yep so the macro question may be more of a comment just I understand the timeline of the all-payer model and and the process for data collection and concurrent with this this five-year project is the fact that we still have a lot of uninsured Vermonters access is still a huge issue thank you and I hope that we can find on ramps in this process before the five years the five-year point to to try to deal with that part of it yeah yeah and I think this model isn't aimed to to do that as you know and I think Ina spent a great portion yesterday I like how you categorize the different healthcare reform initiatives over time so this model is really focusing on on kind of costs and quality cost growth and quality so after you know the delivery side of things but I think you share your frustrations yeah I think it's important for us as we look at this to understand those distinctions and um maybe we'll come back to that later and just some broader questions I I think many of us share the concern but it's not something that this model agreement is crafted to address specifically so it's something that is left unaddressed by us that was hence my language an on ramp to um you know a conversation about an on ramp to other solutions yeah uh representative you want to chime in here just to chime in I you know this is something that came up last year as well and I think the interim message was yeah this is not the focus except extremely indirectly in the sense that if we actually moderate the cost then maybe it'll be more accessible for people to purchase insurance or whatever so it's very very tangential um and and is not actually addressing that leg of the the stool but I'm going to just take my option here as the chair to weigh in with there are there is uh and I'm going to ask maybe we can address this later but I'm just going to lay it on the table because I think the language of these agreements the names of this agreement is uh leads to enormous confusion in the broader public who are unfamiliar with healthcare policy when I hear statements made like I support single payer not all payer and that that's completely a conflation of uh it's it's it's language which is bringing people to a conclusion that is not uh an appropriate conclusion in my view uh and so I think I think we need to be very careful in not uh adding to the confusion that this just it's just the language of that and at some point you know I would welcome you or others to speak to you know what what that language confusion uh or to just speak to that issue so I'm going to go into the other questions uh and I again apologize I think but represent black and then represent golden represent page I have a million micro questions that I will not ask right now thank you since we know that you are you are you have an in-depth knowledge of coding that none of us will ever achieve but well and others I've worked with one care for four years and frankly I'm not sure I understand it at this point yeah I don't mean that a dismissive comment I apologize no that's right I will ask a really cynical macro question okay I understand the premise behind the all-payer model I understand the incentive for payers for CMS but if I'm a healthcare provider why do I want to why do I want to save healthcare dollars why do I want to decrease costs what what's in it for me I mean that's just lowering money that's coming to me so where's the incentive I will turn to either both of you to comment I think the cost growth trajectory is unsustainable as it is and so there's the incentive is a system that if it continues to grow at on the trajectory that it's on a system that falls into disarray and I think that the provider's incentive is very strong in caring for their patients and working within a system that is functioning so that they can provide care okay again I'm going to just take the liberty of jumping in but I think there is it is it not not also the case that moving from fee for service to value-based care gives a greater deal of flexibility to providers in terms of the kind of care that they can provide and we hear regularly that providers are frustrated that they are not quote reimbursed for things which they know they are an essential part of their care but they can so there's this perverse disincentive to in some ways and I think that goes to your question representative black there's in some ways a disincentive there's an incentive to escalate where possible appropriate care but fee-for-service to cover those other costs as opposed to a value-based payment system which incorporates the range of actions that providers know they participated but don't get specific reimbursement for I don't know if that's oh I mean I add it well to add a single other word predictability of payments is what we've heard a lot about yes from the business perspective yeah absolutely the predictability is important but I just I mean I just can't I think providers yes want to care for their patients up most in their minds but they also have to remain profitable and I don't know I just wonder about the all-payer model and really what's in it for them whether there are sufficient incentives built in to actually move to make them consistently profitable I guess I would say to to to build on a representative Donahue's comment and to and to refer back to what I shared yesterday about the the pandemic and the the significant change in revenue from that of course we we hope not to experience disruption of that kind regularly however it demonstrates very clearly the case for the predictable payment to providers and I think suggests that a predictable payment for providers could allow for providers to focus in other areas of their business and of their care model that would improve the outcomes and experience for Vermonters if they have they can rely on the the revenue model that's provided through a budget and predictable payment thank you and as I say there's there's there's many other questions and we can come back to some of those larger issues that you're touching on represent black as well represent golden and then represent page hi and my internet's unstable so I may go off video if I have to but thank you for your presentations I'm curious that I actually have been contacted by constituents who are pretty concerned about the actual budget of the ACO itself and neither of you have touched on that what what kind of money is going into managing the ACO and I'm curious about that I'm not sure this is the right place to look into it I'm also curious about the relationship that UVM and Dartmouth have with the ACO it's sort of that whole management piece I was looking at something from 2019 and had a list of the people involved it was the CEO of UVM and a high level executive from Dartmouth and I'm interested in those relationships with the ACO at some point I'm not sure if you're prepared to answer that now so that's one question I have another two again I'm going to suggest that we might save some of those questions for a further opportunity when we're both hearing from one care as well as from some of the uh from the Green Mount Care Board and the agency I think there's a whole range of questions that that income that touches on yeah thank you just I just want to get them on the table so that we can circle back they're not they're not questions I have they're questions that have been raised before and will continue to be yeah I'm getting actually surprising amount of pressure about it because the negative vibe about the ACO and I think that contributes to it so it would be wonderful to address that we will um um this is on the more micro scale so you were talking about increasing scale and I was wondering how you increase scale in Medicare what would that process look like I can begin and Elena can can can also add um the the Medicare the Medicare program if if as Elena described if you think about how we achieve scale or how scale is counted the first relationship that needs to be established is the relationship between the payer and the accountable care organization so any participating payer needs to have a contract with the accountable care organization in the case of Medicare uh Medicare has the Medicare offers a program and and the accountable care organization participates in that program with Medicare so that Medicare and and the ACO are are offering a program together then the ACO um then the ACO needs willing providers to participate in that payer program that it's offering and it is the willing providers um that would be interested in participating in the Medicare program um that would more willing providers would need to participate in the Medicare program with the ACO in order to increase scale in the Medicare program we do have an example of a recent um provider who's choosing to participate uh Rutland Regional Medical Center is participating starting in the 2021 or performance year four uh with the ACO in the Medicare program for the first time and so that is a having an impact on Medicare scale okay so if I may um if I understand it right then it is in a way once the sort of overarching agreement is designed with whomever it might be the commercial it could be a commercial Medicaid well Medicaid no that's probably not but Medicare then it's provider driven to have to be able to agree to participate is that what I'm understanding okay and if I may um chair Lipper to ask one more question on slide eight one of the goals was increasing access to primary care and I'm wondering where that stands I didn't see any data on the success of that effort um you also related it to the hospital responsibility if I understood that right within that region so I'm just wondering how that gets done yeah so I I think we can I can do a deeper dive I would point you to our quality report to see kind of how we're performing on those measures and I can I can attach the link um recent materials um that's helpful um but you know we'll have the 2019 data um in the next month or so so I you know I think we can look at 19 data would probably be the most um the most up to date so I would I would kind of want to look at that to to before I answered your question so can I just follow up so your 19 data obviously is pre-pandemic so how useful is that given our brave new world I think it tells us something about how we were doing I think we might need to think about what is different now that the pandemic is in play you know people are receiving care differently and I would really you know point to Ina for this one because she's kind of leading a lot of of these efforts and coordinating that so but I think we do need to think about you know how should our measures change in the next model are we going to be relying more on telehealth and that kind of thing so and I don't think Ina can answer more more directly um but yeah so we should think about it thank you thank you this this here uh okay I'm I'm okay this I think we're doing okay it's 10 10 30 I want to give Ina time to finish to come back to her presentation uh let's I think represent page you had a question and then and then I think I'm going to ask folks to hold their questions for now so that we can but we'll collectively decide whether we're taking a break or we're going to hear directly from Ina so be thinking about what break you want or don't want represent page yes thank you chair my question goes back to what Representative Houghton was talking about with the model growing the ACO model um earlier in the year I believe it was the centers from Medicare and Medicaid sent a warning letter to the state of Vermont is that related uh to to that that bar chart that you showed I'm seeing you nod your heads yeah is that affirmative yes okay and then as a result of it um the state then said we're going to open this up to um Vermont state employees so does that bar chart and maybe maybe um the the union hasn't agreed to that yet I I don't know but is that data in in that bar chart to include um state employees being allowed to have access to that I don't believe they're included in the bar chart but I'll let Ina speak to your other questions on strategy and and then I guess the other question is why do state employees get out of out of having access to this that they didn't already have before so I'll leave it there yeah and and with that I'm going to step in and say because that's exactly I mean some of those issues are exactly what we've asked uh Ina back is to tell us about in more detail uh in her next section of testimony which is the agency human services uh upon receipt of that letter Secretary Smith asked for a reevaluation of our progress on the all-payer model uh that that has been completed there's a report and that's what Ina is going to update us on uh that those very questions that are tied to the question that you raised representative page uh and it touches on I think includes the issue of state employee participation so I I think I am going to suggest that while I'm asking others to hold questions right now just in in response to our own health care needs I'm going I am going to suggest that we take a break uh and that we come back and then hear from Ina and and then we'll have time for open questions and we'll we'll be finishing up by uh quarter to 12 at the latest so again in our own interests of our health and health care our health rather than our health care uh let's take a break and let's come back at let's take a 10 minute break and come back at 10 40 please be back on the screen then in the meantime please mute and stop your video thank you let's continue with hearing from uh Ina back us to pick up on the question of the agency human services response in part or in large part to a letter from CMS or well let's clarify was the letter from CMS or CMMI and etc so let's let's turn to uh Elena I mean not well Elena in the background but from Ina to provide us with further information and then we'll continue with questions as we have time hopefully you can hear me I can yes yes I can okay girl yeah in in in September the the state of Vermont did receive a warning notice from the Center for Medicare and Medicaid Innovation uh with whom which is a part of CMS um with whom we well with whom we have the agreement for Medicare's participation in Vermont's model and the warning notice did did indicate that the state um had had uh underperformed on the scale targets that are in the agreement um and asked that the state uh propose um a ask that the state respond to that warning notice the warning notice is not a corrective action plan um we were not we were not asked to submit a corrective action plan I do want to differentiate between those um activities but the warning notice was um to indicate uh that the state was underperforming and to ask that the state respond to that and uh which we did um with with a proposal um for impacting scale which aligns with the implementation improvement plan that the agency of human services put forward in November of 2020 the implementation improvement plan certainly as I just described is responsive to the underperformance on scale targets but the implementation improvement plan is is also more broad in looking at a number of areas in the agreement where we um where we believe that we can perform better in totality all of the partners in this agreement both public and private and where um we we do have metrics that we need to meet um for the agreement that are not exclusive to the scale targets um as well so like we've talked about um certainly improving the for instance um prevalence reducing prevalence and morbidity of chronic disease is a key metric in this agreement and there are recommendations in our implementation improvement plan um that speak to accelerating the progress in that in that arena uh as well and so I'll orient you um there is a comprehensive report which you can um read at your at your leisure uh that that details and provides a context for the findings and the recommendations this uh summary that I will share with you now of recommendations um is oriented in in the four major categories of recommendations that I've described recommendations about our federal state partnership recommendations about the agency of human services own approach um recommendations about the green mountain care board's regulatory evolution as well as recommendations for the ACO and so here in these charts and I'll share four four of them with you there the recommendations are described as in terms of their timing what we're looking to do in the short term versus longer term time frame longer term is described as beyond year 2022 the medium term is described as year 2022 in short term because this plan came out in November was described as 2020 and 21 so of course now when we're talking about short term we're talking about what's happening in 2021 um we we indicate the leads on these recommendations in this in this table as well as the domain of the agreement that the recommendations are are intended to make an impact and oftentimes you will see that many domains could be impacted by the recommendation that's because the the different components of the agreement certainly are um are uh they interact with one another and there is there is a total impact um that is often uh that is often a function of scale for instance um of the of the um of the agreement so I'll begin now in describing these recommendations um the in in the arena of our federal and state partnership we we recommended that we do need to work with our CMS partners to be sure that the scale targets that we have in this agreement are reflecting a realistic capacity for participation and right now the scale targets do hold us accountable for some Vermonters to be attributed to this model um that cannot functionally be attributed the way that the model is set up and we would like to work with CMS to see if we can be um for lack of a better term relieved of that responsibility where the state actually doesn't have any uh the state doesn't have any power to make an impact and that that doesn't uh those changes we think are fair and are important so that they're the scale targets are realistic however they those changes don't um suddenly make scale a problem that doesn't need to be addressed in other ways as well it's not just that the numbers are wrong and we're doing just fine we do need to increase the participation of peers and providers in this agreement but we thought it was important to reflect a realistic target as well we are um we we also have um accomplished the reduction of the risk corridor thresholds for the Medicare program that the ACO is participating in the the risk corridors um what their value there was uh previously was such that it was creating a a significant financial burden uh for participation for particular hospitals um and and in in with COVID-19 really opposing a burden of participation for any for any participant uh working with the Green Mountain Care Board as signatories in the agreement there there was a proposal made to CMS to reduce the risk corridor thresholds um in the near term and that proposal was accepted and has occurred for the 2021 performance year and therefore we are seeing some more participation in the Medicare model than perhaps we otherwise would have seen um as I indicated the Rutland Regional Medical Center has has joined the program and you say something more about is this does it I am I remembering that there was a proposal to basically hold harmless for uh some period of the pandemic from the risk corridor or is that am I confusing several things here the the risk corridor proposal is it is a near term proposal meaning for this 2021 performance year um it is it is not necessary it it is not necessarily um uh correlated uh specifically to the pandemic okay can I add one thing though I we there is no lower there is no risk for the duration of the public health emergency so um there's only upside risk and no downside risk um just across all of the Medicare um models can you can you say say that again in a different way so that when you describe upside and downside risk so there is there's no risk to um participating ACOs um or providers um participating in these alternative payment models for the duration of the public health emergency um so this risk corridor which specifies what you can win if you you know save health care costs or save on health care spending versus what you lose by overspending on health care um now if if there is you know if you don't hit those targets that are prescribed and you overspend you're not going to be held accountable to repaying that um to CMS for the duration of the pandemic and is that is a measure of the duration of the pandemic measured by a federal declaration it is yes and what what is that do you can you remind us what the federal declaration current I know at the state level it's renewed it's been being renewed monthly or something close to that and I believe there's something different I'll have we can get back to you on that I think we expect it to extend quite a bit into 21 from what we've heard um at the very least um you know there are a lot of variables at play a lot going on with the pandemic which would impact all of this so yeah that's what I was trying to point to as well so thank you thank you welcome in order to improve participation in this model we also um would like to work further with CMS to ensure that we have clear guidance for the cost reporting requirements that critical access hospitals have uh critical access hospitals have cost reporting requirements as a critical as a critical access hospital when when they are participating in an alternative payment model um how they meet those cost reporting requirements becomes complicated we are really looking um to be able to disentangle that complication for the critical access hospitals so that it's very clear um how they are to meet that obligation of reporting even though they are participating in this alternative payment model we also propose to establish a path for the Medicare payment model to mirror the Medicaid next generation fixed perspective payment I mentioned this a couple of times already in my testimony that well the Medicare model is innovative for Medicare it is not as innovative as our Medicaid model is and we and our Medicaid model offers a true fixed perspective payment that is not reconciled to fee for service performance um and and that is where we want the Medicare program as well to go we need to evolve the Medicare model further so that um providers are are getting a true budget and that that budget through the Medicare model is not then being chewed up to the fee for service claims that that are coming in through the system rather that if the providers in the Medicare model perform well in that budget then um those those savings um due to that performance are ones that they keep the the the Medicare model can be simplified said another way the Medicare model can be simplified and the payment can be operationalized um to be more attractive we also propose and recommend that the Medicare 2021 benchmark provides as much stability and predictability as possible despite the ongoing uncertainty associated with the pandemic this this actually came up in discussion um related uh to our our earlier presentation this morning um in terms of how the pandemic is impacting this model um certainly that the the pandemic is completely unforeseen in the planning of this model and also really needs to be taken strongly into consideration as we are using in the model um historic performance in delivering health care services to be able to set future health care spending goals budgets targets and so on and when we have a disruption like the pandemic where usual patterns of care are are far from normal we have to be very careful in how we then use patterns of care to set a growth rate um or a benchmark for a future performance year um so we are working with our partners to ensure um the most stability uh that we can that we can given these factors we it would also seem that it's imperative to actually to try to as much understand as clearly as possible what the impact of the pandemic actually has been so that uh i mean i've frankly over the course of the past period of months during the pandemic there have been both speculation as to what would be happening and there's some data as to what has been happening in terms of reduced use of health care and others saying will they expect a surge in use of health care following certain periods of you know closing down elective care etc so i think there's a lot there's a lot to understand what's what the actual impact has been or is is happening and has been absolutely there there is an there has been an impact there will likely be impact moving forward and we and we can also look back to preprint pandemic patterns of care and use those to inform what we would expect health care spending to look like in a recovery as we recover um so i think that that's that's the that's the work that needs to be undertaken in partnership certainly with our federal and other payer partners we recommended finally in in relationship to our federal and state partnership that um the state collaborate with cms the mmi to encourage the health resources and services administration also known as HRSA um which governs the program for the federally qualified health centers to prioritize how federally qualified health centers can participate in value-based payment models so that um we have we have and can describe opportunities for federally qualified health centers in this model and that's a that's a longer term recommendation but in important one when we are aiming for a system-wide approach and a system-wide adoption of the fee-for-service alternative methodology the next category of recommendations focuses on the agency of human services and how it prioritizes and reorganizes uh to align with the goals of the all payer model the first recommendation is for the agency of human services to conduct education and outreach to non-participating self-funded groups as i said the agency of human services through its Medicaid program has a particular experience um in contracting and paying for health care differently that is educational for other payers that are considering participation and in and in the immediate term we also would recommend the participation of the state employee health plan members for attribution to one care in performance year four 2021 and that as you are aware that decision has been made and the state employee health plan members will be attributed to one care vermont in 2021 representative page asked what the benefit that would be for those members the benefit is those members of the art are going to be attributed to the accountable care organization a network of providers taking responsibility for cost quality and outcomes there and and therefore the the activities of care coordination and improving the deliveries this will touch those those and can benefit the state employee plan members um as well as the state employee health plan members benefit benefiting from the system-wide participating in a system-wide approach to um cost growth moderation representative page you want to well yes just a quick question what effects what effect will it have on this policy what effect will it have on our primary care providers do we know that yet will it have any either pro or con are you referring to the i'm not sure your question are referring to the state employees particular yes yes participation yes thank you primary care providers are are are delivering care and are doing so in in this model for their for their patients and i think that if you ask a primary care provider they will they will probably answer that they're they're coordinating care and delivering care consistently across all of their patients kind of regardless of a payer of who's paying but i think when when we um when we have more people attributed to this model and more payment is provided for in a value-based manner that the incentives for the system to emphasize the work that primary care does and to um and to ensure that primary care is um is is supported in its prevention and health promotion activities and that those incentives get stronger with more payments being value-based than fee-for-service well that that may be correct but it also when it also put more stress on the system more stress on on these providers that are already um perhaps have enough uh to do as already i think that there's a very important balance um and and calibration of how we measure um how we measure the uh care delivery and primary care providers um are subject to measurement and i think that there's very good work happening in the field uh to be able to to be able to um look at the the measures um and evaluate the measures and ensure that those measures are um contribute contributing to the outcomes that we want to see um and certainly evaluating where um where emphasis should be uh applied um and and to try to uh streamline administrative burden where possible the the the alignment goals in the model are certainly um are certainly aimed at addressing some administrative burden for providers who in the system left alone the system has um a host of different rules and regulations that differ by every single payer um the spirit of this model is to try to align rules and regulations so that they look at an emphasis on care care quality to align that across payers so that there is a more single focus for providers rather than myriad focus dependent on the payers that they contract with we also recommend that we prioritize the integration of the claims and clinical clinical data in the health information exchange and organize the health information exchange activities within the office of health care reform in the secretary's office at ahs so that this work can be coordinated uh can be ideally coordinated with um certainly the all payer model and so that the um work of the hie steering committee is as coordinated as it can be as to align with the goals and outcomes in the all payer agreement we also recommend partnering with one care vermont and delivery system users to evaluate the efficacy of the care navigator platform um i i i would certainly encourage one care um when you speak with one care to describe the care navigator and and how it is um meeting the needs of care coordination for for its network however we are recommending this activity because there has been a lot of feedback from the field that care navigator um can be improved and we want to be responsive to that feedback and we think that the certainly the care navigator platform or the care coordination platform um is essential for the delivery system reform um that needs to that needs to allow for more coordinated care across care settings and across uh different provider types we uh we will consider through a phased proposed approach conditioning um provider participation in agency of human services blueprint program and in the in the patient center medical home payment component of that program um uh in particular to be contingent on participating in the value based payment arrangement with an aco we the blueprint is a foundation um for healthcare reform it is providing uh very important resources to strengthen primary care and to provide for community health schemes but the blueprint is not moving the system away from fee for service we would like to see um potentially with time the blueprint be a foundation that is aligned with our goals to move away from fee for service this is a longer term recommendation but i do want to note here that in the 2021 performance year for those providers that are taking risk in the Medicare program that they will those providers who are participating in the aco taking risk in the Medicare program they will be receiving a slight increase in blueprint payments over those providers who are not participating uh in the Medicare aco program this is a small incentive to participate in the aco uh model the next recommendation ahs one care vermont and community providers should improve collaboration to strengthen integrated primary specialty and community based care models for people with complex medical needs and medical and social needs and in order to accomplish this the vermont um chronic care coordination initiative will be organized along with the blueprint for health in the secretary's office this recommendation really looks at the role of ahs as a partner in this agreement and particularly in providing for care that is coordinated across a diverse number of settings and um we we seek to better align this coordination and certainly um to be working in partnership with our health care partners including one care vermont to strengthen the degree of coordination that's happening across uh community based care settings in particular we also recommend that the agency of human services along with one care vermont and community provider partners identify a timeline and milestones for incorporating social determinants of health screening into the standard of care in health and human services settings um we also recommend that the blueprint for health along with one care vermont and ahs um explore jointly with stakeholders the best available tools for capturing real-time patient feedback and this is in particular to the primary care um access to primary care outcome that we are looking to improve um we're looking to improve access to primary care we think that there could be some um real opportunity in having some better real-time feedback about access and experience with primary care and we don't have a good um methodology at this time to really have a sense of what's happening on the ground in the in the very near term with respect to access to primary care finally the agency of admin of agency of human services excuse me on the green mountain care board uh together we are looking to prioritize regular stakeholder engagement opportunities and I um I I do recognize that this activity uh we we have it uh absolutely as a short term priority and we do and will be engaging in this activity recognizing that stakeholder engagement opportunities look differently uh in the pandemic um and that the way that those will be offered um are in the short term going to need to be remote and also need to be cognizant of the considerable uh work that our partners are all doing in response to the pandemic at this moment in time recommendations for um the green mountain care board in in and thinking about the regulatory um response or the regulatory structure uh that's governing our our healthcare partners as we implement this agreement the green mountain care board um and ahs together will request will request that blue cross blue shield vermont as well as mvkey and one care vermont identify clear milestones for including fixed prospective payments in contract model design this is really a partner recommendation to the one um where we are looking for our federal partners to move more quickly in including a fixed prospective payment component in the medicare payment model this is mirroring that recommendation but for our commercial payer participants in this model the commercial the commercial payment model is again not as advanced as we would like it to be in including a true fixed prospective payment component in its contract model design under the authorities of both aco and hospital budgets the recommendation here is for that the green mountain care board should explore how aco participants can move incrementally towards value based incentives with the providers that they employ that means uh if you are in a alternative payment model uh and the model is emphasizing um for instance like a certain quality outcomes that perhaps providers through their contracts will be rewarded for the quality outcomes over other potential uh contract components um that emphasize the volume of services performed rather perhaps than the quality of services performed annually in its budget presentation to the green mountain care board one care vermont should identify the cost growth drivers across its network and detail its approaches to curb spending growth and improve quality and finally recommendations relative to the aco's leadership strategy and how to strengthen that leadership strategy I think in particular um both to capture more participation in this model but also um certainly to maximize on the potential of the model to moderate cost growth and improve quality we recommended in our report that one care should elevate data as a value added product for its network participants and provide the necessary support for those providers for leveraging this information for change we recommended one care focus on entrepreneurship and how in trying to attract more participation it can ease providers transition to value-based payment and delivery system redesign we recommended uh in addition that one care identify and perfect its core business provide useful actionable information and tools to participating providers and this recommendation is really coupled with um what you see as number 13 and that one care should improve how it packages data for providers we recommend one care foster a culture of continuous improvement innovation and learning through this focus on data and providing systems for improvement and systems for tracking of results so that providers can see uh how their interventions are clearly linked to changes in result and finally improving transparency and responsive to responsiveness to partner requests for information um both partner pay your partner requests uh for information as well as regulatory requests for information and that those are those are our four areas of recommendations uh i might note for those who have the report either electronic or printed form that a good deal this not all of them but a good deal this are summarized on pages 20 20 and 21 of the report if you've had the chance to look at the report as well so i see that we have some questions i i'm gonna start i'd like to throw out one question first thank you inna and um so we're sitting here as the legislature uh as the health care committee of the house reviewing uh these recommendations understanding trying to understand the all of the various dynamics at work in the accountable care organization model uh which is an agreement that uh was authorized to be signed in act 113 and which is a where the signatories are the agency human services the gremat care board and the governor um what a question that has that comes to mind is uh in the recommendations listed here are there any there were do not appear to be any directed recommendations to the legislature per se uh and i'd like to ask you to comment on that there are not any directed recommendations to the legislature that's correct the recommendations are really directed at the partners in the agreement that were described in that pillar diagram um both the partners and signatories on the agreement as well as those partners who are essential partners for implementing the agreement payers and providers and accountable care organizations and so the recommendations are ones that um are made uh in in the spirit of those of those entities um having uh within their means um the resources to make progress on these recommendations absent legislative action great and would it be fair to say that the recommendations uh which are you know numerous and directed toward different entities uh are premised on the fundamental decision of the agency human services to continue moving forward with this model uh through the period of the contract and to or the agreement uh and to pursue a possible to pursue to negotiate a further agreement or possibility of a further degree agreement can you speak to because i think i think one of the questions that is raised in the public's mind is the letter from the quote warning letter is this a letter that suggests that the agency is the agency or the governor or the green mount care board is contemplating stepping away from this agreement at this point in time and i think that's while it's not stated in the recommendations it's implicit but i think it needs to be made explicit and i wish you'd and i'd like to ask you to comment on that absolutely we are not stepping away from this agreement at this time whatsoever we are we are stepping in to identify where we can make this agreement work as well as it possibly can for the state of vermont to realize its goals of moderating health care cost growth improving health care quality and moving our state further towards a more seamless model of care across settings and across a variety of settings that are important to health and well being in partnership with health care settings but not exclusively to what we would think of as health care setting okay and and then lastly is there is their current activity in looking toward the possibility of a read of a negotiation for a further extended agreement or a new agreement certainly we know that we've that the agreement lays out timelines for proposing a next agreement which is helpful so we are we are having we are certainly aware of what those timelines are um and are and are talking about how we approach how we approach the requirements that are in the agreement which um there is that it is it is required that we propose a next agreement um in in about a little less than a year's time from now so there's a lot more to be heard about that at a future point in time right yeah um thank you and again i think i think given the the range of questions that are being raised that have been raised by different stakeholder or not just even stakeholders but by vermonters and others uh i think it's important to be explicit that the administration continues to stand behind moving forward with improvements on this agreement and not stepping away from this agreement that's correct yes thank you yes uh represent donahue and then represent black represent page i think we're doing okay but representative black was ahead of me i'm choosing to ask you to ask your question first i'm the chair at the moment thank you i just didn't want to no i understand i just felt like it was useful for let me explain is my is my practice as a chair to try to give voice to persons who have not yet had a chance to speak or speak very often and i'm not trying to stifle representative black in any manner thank you um and this sounds like a comment because it starts out that way but it really is a question or um information i you know there's been a huge frustration with this process because it seems to be such slow progress on reform and usually there's responses well but it's it's huge it's a huge change to make it's really pretty um it it takes a while for this degree of change one of the things that um has not been clear and you referenced it a little bit is when we talk about scale of participation that actually a lot of that participation is not participation is not participants who are actually doing payment reform yet they're signed on but they're still using fee for service so that fundamental shift isn't occurring i think it'd be helpful to know those percentages i know that for instance from your material the um private providers are maybe even further behind on how much participation includes a change away from fee for service but but knowing those percentages for those categories i think would would help but the even bigger piece from the start has been really clear that scale is critical this will not succeed unless it has um you know the vast majority of Vermonters participating um and it's always been it's been an ongoing worry of mind that we haven't been meeting targets for scale and i know it's a chicken and egg you can't get people willing to join if they're not seeing or it's harder if they're not seeing benefits but they're not going to see the benefits without a bigger scale so uh you know your first bullet point there is it's a concern to me um about progress of the model to say we're going to revise downward the the targets of what we hope to achieve um for scale and i guess i i would like to know how much i think it'd be helpful i don't think we had a slide in this overview yet we had one that showed what percentages were participating but there used to be one that also showed in comparison to the target the that because it was a target for each year progress and how much behind those are would be helpful to see as well as to see the contrast to what is being proposed for um new targets for participation i'll speak to that question first the the intent of the scale target if we are successful and we may or may not be is not to move away from the preponderance of Vermonters being attributed to this model because of the principle that you just stated that it's it's not going to be successful unless most of the payment in the system is changed uh however the the success of providers in managing care also happens in how the care is delivered coordinated and the structure of the delivery system there are some Vermonters that are not receiving the majority of their health care in our state and for those Vermonters who are getting most of their health care out of state their attribution to the model is number one it's not func we can't do it because their providers aren't in the state of vermont and number two those Vermonters that are receiving most of their care out of state for a variety of reasons that care can't be managed by our system to improve it and so they are not realistic for attribution to the model in our estimation that it's not a significant number um it does not i don't think that it would detract from anyone's assessment that the preponderance of the Vermonters would still need to be attributed um the first question you asked about the um about the percentage of of payment that is moving away from fee for service I this this um I do want to be clear that all of the payment models um were the most and Elena can can perhaps um give you the overview of exactly um the way each contract looks and shapes up they qualify these models do qualify as aco scale target initiatives and they meet the requirement of our state and federal agreement as being alternative payment models um in the eyes of the federal government and in the eyes of um what's called the learning action network which has a framework for moving away from fee for service the commercial contracts with one care are are moving away from fee for service because they have a shared savings component they have risks and they have a value component so they are they are not just traditional fee for service um pay just pay as you go with no connection to quality or value um there is those do exist there but we are really trying to push the envelope and push further for that true fixed perspective payment to be a feature of the contracts and and we are really emphasizing because we agree that that is going to have that is going to ultimately be the strongest incentive and provide the best predictability as we saw with the pandemic but I did want to make that distinction and and be clear that while we're pushing really hard for that the contracts um that exist today they are not just fee for service um as as usual they they are innovative too yeah I think it would still help to kind of know what those breakdowns are and and particularly most basic that um the difference between current percent attribution and target what the targets had been thank you I can clarify on the on the fixed payment if you're interested in that um so I think in terms of all fixed payments that includes Medicare which is primarily a cash flow mechanism um based on one cares 2021 budget that's about 34 percent of the dollars flowing through one care so if you remember back to that bar chart in terms of our total health care expenditures it's 34 percent of 10 percent if we're talking about truly fixed payments um that's really only the Medicaid contract that's only 12 percent of the dollars flowing through one care so 12 percent of the 10 percent of our all of our expenditures so that shows you just you know it's a very small slice um and I think there might be some you know population-based payments outs you know for that outside of that that might increase that a little bit like for blueprint etc but thank you uh representative black um I think representative golden and page and so I have two questions um first one is Medicare part C are those patients attributed are you concerned at all with the increase in um enrollment in part C it's it it's it is a it's a great question uh those we are seeing um increase in enrollment in part C it's uh it's not astronomical um Alina might want to talk more about it because the Green Mountain Care Board does does um do some tracking of that um but those those Medicare Advantage plans um per um our federal partners are not included yeah okay can I just can I just say Alina I I have the same the same question uh because I think they're I think we can anticipate that there's going to be a greater uh penetration of Medicare Advantage plans uh based on particularly with Blue Cross Blue Shield of Vermont well and starting there and others yeah I I'm not prepared today to to quantify that but it is something that we are like looking at and it has kind of we've seen an uptick and even you know in the in the coming years um so and we are you know talking about it with our federal partners as well to understand kind of how they're thinking about you know these plans yeah uh my other question was regarding number 14 on your recommended report making participation in blueprint contingent upon also participating in one care doesn't that seem a bit coercive it's something it's a longer term um it's a longer term recommendation and the recommendation is that it is something to explore uh it's not necessarily um at this time yes one one care is it it would be contingent on participation with one care accountable care organization um but we certainly think if our objective it's worth exploring this we do want stakeholder input we aren't making this decision lightly it's not happening uh now um but it's worth exploring if our objective as a state is to move the system away from fee for service and to and to um and to have a value-based payment system for as a as a statewide system um whether our blueprint program offerings are consistent with that objective represent Goldman represent Houghton represent page um the the question came up um of not for profit and for profit yesterday or the day before I don't know they're all blending um but I understand that one care is considered a for-profit entity and I think I know we're going to talk about that structure at some point so I just want to get that on the table but I'm also wondering would that um sort of conversation include a legislative remedy or where that might be thought of um if we thought that needed to happen yeah let me let me let me speak to that innocent that's that's that's that's come back to that this is an issue that's raised on numbers of occasions and there's frankly great confusion and about what that is and uh and the distinction we were making uh in the other yesterday about for-profit and non-profit hospitals it's a different there's a there's different issues involved here but I think I but we need to talk about it because it needs to be understood so we will come back to that absolutely represent Houghton represent page uh Ina with this all these recommendations um was there any type of agreement between the players who are responsible for achieving them on accountability of achieving them you know how how are we holding everyone's feet to the fire I guess um we that's a that's a really good that's a really good and fair question um I I believe that all of the players and certainly um they they can also speak for themselves are committed to improving in this model and that the uh recommendations that we've made um do align with known areas for improvement among these entities the Green Mountain Care Board staff did um provide consultation to us in in creating the implementation improvement plan and um and share uh and share thinking about how uh improvements can be made um we don't have a direct accountability mechanism that we built into into the report um for those partners who are not ourselves we're certainly holding our own feet to the fire to accomplish these recommendations um in the near in near term in the medium term and in the longer term we have moved now the blueprint team reports to me in the secretary's office we've changed that reporting structure um we are working with um one care on looking at care navigator um we've gotten right to work on these recommendations and as you saw some of them have been implemented successfully already such as the Medicare risk corridor change which is in effect now as an example but I think you're I think your question is uh well taken and thank you there's a page yes thank you chair um I have a couple of critiques and and it goes to some of the questions that have been asked before um particularly with the chairman Lippert um you you mentioned that um AHS is not stepping away from some of the agreement with one care but um there does appear to be um there is an appearance that perhaps agency of human services and maybe the administration might be a little bit too close to one care and um I'll just leave it at that I realize that you have to work with that organization but it just it just to me anyways there there is an appearance maybe too too much coziness um the other the other critique is at looking at your your strengthening some of your leadership strategies some of these things appear as so why wouldn't you have done these things before um they seem rather simple items um that should have been should have been uh focused at the very at the very beginning of your relationship with the um with one care and I just like for instance transparency or providing useful additional information I mean those things to me seem very basic uh quality uh management things that that should have been done you know from the very from the very beginning so those are just my two my two um critiques thank you um thank you uh represent Peterson and then I think we'll see if there's any other questions for the witnesses and then we will come back to this with committee discussion and also with the opportunity to hear from one care itself given that they've been uh the subject of a lot of uh comment along the way we we need to hear from them and as well so represent Peterson yes I'm glad I'm last and I purposely didn't put my hand up till last um Chairman Lippert you spoke very eloquently to me when you talked about all pair one pair and the average public doesn't know the difference and I'm sitting here watching and hearing all of this today and yesterday um it just I'm a former football coach so I have to around the Super Bowl have to use a football analogy this stuff is like somebody designing a complicated football play to a guy that's trying to get a shoulder pads on right I so my question will be a softball for this group of folks I appreciate all you've said but I'm I'm just struggling to catch up and I will uh I read it and I I try to I try to catch up it just is is tough when you you're not in the field and haven't been here um my question is one care is one care the state insurance company is that what one care is it it is not I'm seeing a shaker head what is one care I I guess I want to start there um and see how it compares the Blue Cross Blue Shield MVP Medicare and Medicaid I guess I just don't get I wonder if there's a flow chart somewhere that shows a flow from one to the other so that so that a person can see when somebody walks into that doctor's office where the stuff go so what is one care I think representative uh Donahue may want to jump in here for a minute first well just just to suggest that to step back slightly at one of the pieces we I don't think we really look explained yet is how did accountable care organizations come into being what's their place in this and then that'll help understand well you can do it that way but well that that'll explain it out of it and just what is one care that's what I want to know okay and and art you know I appreciate I appreciate your uh work to jump jump into something uh that's incredibly complex uh from from uh baseline of not having worked in healthcare or done healthcare policy I I completely appreciate and I actually appreciate your perspective that that helps us to that requires us to really think more clearly so well I just think there's a lot of folks out there wow 99.9 percent of the folks yeah have no idea absolutely absolutely you know I'm just trying to struggle through it so I thought I would just get that piece and that's why I asked them to chat and Nolan may be listening to this I'm going to reach out to Nolan he offered to get you and and try to learn that's all I want to go hi Nolan but I'll email you but anyway okay so given the time we have I'm going to ask for I'm going to turn to Ina I guess uh and you're going to get a less than full answer because it's not it's not straightforward uh and we will be coming back to this again and again and uh but let's Ina feel free and thank you art for your question one care is not the state of Vermont um one care is a private entity and one care is a private entity that is made up of healthcare providers it is a network of healthcare providers that participate in in and as part of or that they make up one care Vermont um the providers that participate in one care Vermont include hospitals it includes um physician practices that are not affiliated with hospitals it includes designated agencies it includes just in terms of the designated agency jargon meant mental health and substance use disorder services providers and home health agencies too um are all participating in the network of providers um that that makes up one care Vermont one care Vermont also has uh its team that administers its work which is to provide its network with information and data um and strategies to deliver care in a way that's more efficient and higher quality okay and that is an ACO as Representative Donahue pointed out it's an ACO and it is the only one we have right now that's the agglomeration of okay yes there was a time when multiple ACOs were contemplated but they did not materialize uh that's you know pieces of the history yeah okay that's fine i will leave it there that that answers with my basic question that's one thing a thousand other questions but that's fine of course yeah of course and and can i thank you very much jenna thank you representative and i and this is it's useful that uh sarah berry has been listening uh from one care uh we will and i made a note to myself we need those of us who are ranging agendas need to uh be certain that we come back to hearing from one care and perhaps others sooner rather than later so that we're able to benefit from the testimony we heard today and not get diverted which we can easily into many other issues um so we will do that but this is useful i think for sarah berry and as a representative one care to have heard some of the questions that are being raised here today and uh to emphasize the need to uh have folks understand uh both the role of one care and the uh the role that one care plays within this larger agreement that we're talking about which which is in fact an agreement that is not contingent on one care it's a contingent on an accountable care organization existing and it happens to be one care uh but it's not a federal agreement with one care i think that'd be fair to say that that's sometimes confusing as well so we've covered a lot of ground here this morning and i appreciate everyone's participation genuinely i want to thank ena and alaina both of you for your part in these presentations i want to thank the committee members for raising questions which uh and when i've on several cases said well look can we set that to the side and come back to it or we will talk about that more this is i i'm not really intending to try to say well i don't want to talk about that it's really a matter of trying to see how to facilitate us moving forward with the timeframes that we have uh we will talk about every issue that committee members have brought up um but i think uh given again our overarching goal of maintaining our own ability to function on zoom as a legislature uh i think unless there's something else that i need to be reminded of i think we're going to close our testimony and hearing this morning um i'm trying hard to do that at by quarter 12 because some people have noontime meetings and at least give us a transition time off camera and to deal with personal family and because most of us are legislating from home and again i think we just we cannot forget what we're all doing this within the context of the pandemic this this is the reason uh i mean this that that and when we talked about the healthcare providers and the healthcare system i just want to underscore that our whole healthcare system is operating and laboring under the impact of this pandemic and so that and the pandemic is impacting all of all of our monitors in so many ways and that that continues to be our primary focus as the legislature as we try to move the state forward safely successfully amidst this pandemic while trying to maintain initiatives that have been underway so again with a great deal of appreciation for every healthcare provider in the state of vermont thank you um and we'll continue to try to find answers to all the questions we have as we move forward