 Good afternoon and welcome everyone to the Green Mountain care board meeting. My name is Kevin Mullen chair of the board The first item on the agenda is the executive director's report Susan Barrett Thank you, mr. Chair. I don't have a significant amount to report out only just to remind folks that they should just keep an eye on our website and our Press release for upcoming meetings, we have a couple of meetings next week and the week after that our TBD But we will certainly warn those Meetings if there anything if there's anything added to those agendas and we'll adjust the press release and I and I believe there already was an addition this week we added a primary care advisory group on Wednesday October 21st, so just keep an eye on that and that's all I have to report out Thank you, Susan. The next item on the agenda are the minutes of September 29th and September 30th. Is there a motion? It's not moved Second It's been moved and seconded to approve the minutes of September 29th and September 30th without any additions deletions or corrections Is there any discussion? Hearing none all those in favor signify by saying aye. I Those opposed signify by saying nay Thank you everyone So the first item on this afternoon's agenda will be a Discussion of the quality standards and for that I'm going to turn it over to Michelle degree to tee that up Michelle Thank You chair Mullen. So We are here today to discuss the final 2019 quality results for the one care payer specific contracts and So as GMCB staff, I'll be wearing two hats today I thought about actually like bringing hats, but I didn't So the first one will be as GMCB staff just overview of the program requirements and what we're looking at here today And the second sort of role that I'll play today is in reviewing the actual Medicare results for 2020 2019 not 2020 for 2019 So what I'm going to do is Introduce everyone that I have with me here today. So from Diva I know that I have Pat Jones and Amy Coonrat on the line From Blue Cross Blue Shield. I have Andrew Garland and Tyler Gothir has joined from one care of Vermont So hello to everyone What I will do is share my screen and I will advance the slide throughout the presentation So once I'm done, I'll pass it over to Medicaid Just give me a signal and I'll I'll advance the slides for you And with that we'll go ahead and get started Can everyone see my screen? We can. Okay. I'm gonna turn off my camera while I advance and get started so First things first just a quick agenda for today But I just kind of went through but I'll be providing some background Just on the results that we're looking at here today Then we'll review each of the payer results. So we'll start with Medicare Then we'll go to Medicaid and commercial and then there's the opportunity for the ACO to provide comment This isn't the same format as we did this presentation last November Then we'll go to board questions and public comments Starting off with some background I Just want to kind of remind folks that today is about assessing performance on the ACO Quality measures that are set forth in the payer contracts between the ACO and the and the payers This is not an evaluation of the all-pair model quality performance as a reminder We measure all-pair model quality report performance annually It's very likely that those results will not be released until early 2021 For the 2019 year, we're just starting to get some of those data in obviously we have the payer specific data But in terms of the claim space measures that we need to evaluate We need a little more time for claims run out and for the 2019 year to be finalized So that said Again, just noting this is solely a reflection of the ACO's performance relative to payer contracts is not necessarily Those contribution to the state's performance within the all-pair model agreement Though I will say we're currently exploring ways in which we can interpret these results in the context of APM performance And I'll talk a little bit more about our thoughts on that a little later in in the presentation So under the agreement just a reminder that the ACO is a legal organization of healthcare providers that agree to be accountable for the quality Cost and care of the beneficiaries assigned to it The ACO scale target qualifying programs must reasonably align in their design across payers, which includes ACO payer quality measures And so you'll recall that back in 2018 we did a significant amount of work With the HCA and one care around designing the Medicare measures starting in the 2019 year So we'll see those results Here in a moment My famous crosswalk that I get to update every year So this year we're actually looking at the full suite of all-pair model measures here in the first column and you can really see that We're starting to see some pretty great deal of alignment across payer programs So you have the 2019 Medicaid next generation program in the second column The third column is the 2019 Medicare initiative and the fourth column is that Blue Cross Blue Shield next generation program I do want to point out a couple of quick notes here For example the initiation and engagement measure Blue Cross does treat those as a composite the all-pair model the Medicare initiative and Medicaid next gen do treat those as separate measures and so anywhere that you see sort of Locked cell is just to indicate that the payer in that case That's those as a composite measure Another note here just before we get to into the weeds Caps measures that is the consumer assessment of healthcare providers and systems as of the patient experience surveys Each program has some type of caps survey That they Distribute but they're not necessarily all the same and so a couple of quick examples The all-pair model includes the cap survey Composite of timely care appointments and information for ACO attributed Medicare beneficiaries only But the Vermont Medicaid next generation program Includes multiple caps of patient-centered medical home composites. You have The Medicare initiative using multiple ACO caps composites for attributed Medicare beneficiaries and similarly with Blue Cross They include care coordination composites and tobacco cessation questions from the caps patient-centered medical home group and just to Consolidate this List a little bit. It was easier to make those sort of one lump But each payer and goes into detail about the cap specific measures within their programs So with that just moving forward while working towards payer lineman is a primary Active not all pair programs are equivalent in terms of quality requirements. Again, you'll recall in 2018 We went through that work group to develop and propose the measure set in the Medicare initiative From 2019 to 2022 and so similarities across the programs are much more noticeable in the 2019 program Year than they were in 2018 And differences that remain are primarily due to types of covered lives or aligned beneficiaries And and make quite good sense. So for example, there's a lot of a couple of adolescent measures for Blue Cross and Medicaid Populations but not necessarily for Medicare and that just makes sense based on their covered population so, I know there's going to be a lot of Questions about what can we say year over year in terms of Advancements or changes in quality and so while we do now have two points in time Comparability is still a challenge for us and I apologize if you can hear my dogs So performance year one 2018 and performance year two 2019 data have been finalized We're working with our analytics team as well as some of our outside experts to dig into changes in quality associated with populations and other factors and so just to sort of highlight that I wanted to show a Quick snippet, you know, we've we've now produced two scale reports also And so this is just showing really that population shift so the increase in the Medicare and Medicaid populations in that Small decrease in the commercial program from 2018 to 2019 to just show how that shifting population has the potential to impact our results and our quality measures And again, that's something that we're looking into and how we can address to start to look at this more longitudinally switching my hat Medicare for 2019 So in 2019 similar to 2018 there were four domains for Medicare We have patient and caregiver experience, which is worth 20 points I just want to note here that's half of the total points and they're all based on those Cap survey questions. So that's patient experience Accounting for half of the total points available There's a care coordination and patient safety aspect two measures there. There's a preventive health Section those there are four measures there a couple of notes on these so for preventive health in the at-risk population There were measures that were initially stated to be paid for performance and they reverted to pay for reporting As all activities related to the quality measure validation audit for 2019 year were canceled and that's due to the public health Emergency so that was a choice by CMS to revert those measures to pay for reporting since they could not Perform the audits necessary to give a total performance for So here's the 2019 results I know this is kind of small but I can leave it up on the screen for a bit while we start to talk through it I did want to note So I tried really hard to come up with a creative way to show 2018 compared to 2019 and this is the easiest so Every measure that has a star next to it was also reported in 2018 And so those will be part of the measures that we look into or that we work with one care on Thinking about how we start to look at these in a longitudinal manner. How do we think about the population? some of these and how do we You know start to to think about how to really trend this data We don't want to make assumptions based on this because we know there was a pretty significant growth and that just that you know The overall denominator would have a pretty significant growth So a couple of notes here for that for the Medicare results specifically Caps measures combine responses to several questions and as such performance on caps don't represent an actual percentage But rather the ACOs mean or average I can't say whether or not that's consistent across pairs I would imagine because they're all sort of on different planning scales, but I just wanted to point that out So in most cases, this is a percent score in the case of caps. It's actually just the average score The risk standardized and the all condition readmission measures So those both of those care coordination and patient safety measures are actually inverted so a lower score is going to be better there And and you'll see in a future slide. I made a mistake. So Abigail I will our slides, but I will I promise I'll do that and and For this at-risk population section down below here This is where you start to see the inclusion of those those measures that are also part of our all-pair model set That we're not Asked of the ACO in prior years So that's where we look at follow-up after discharge form from the ED for mental health alcohol or other drug dependence And then mental illness and then the initiation and engagement measure looking at that for the Medicare population as well Okay, so for 2019 quality results There were 20 measures total. So again two point maximum allows 40 possible points The ACO's earned score was thirty six point seven five which results in about a ninety two percent quality score for 2019 and again just to note that those Related those that required a QMV audit were canceled And so there were five measures that the ACO did receive full points just for reporting on And again when these results when the all-pair model quality results are final We'll work to figure out how these pair specific measure results impact the state's performance and we'll have more insight That's how to look at these longitudinally. That's something that myself and the A team are really Interested in exploring and and trying to make sure that we can provide an accurate snapshot of performance year over year for the model I did want to give you a quick reminder of 2018 so jumping back a year. We went from 29 measures to 20 and the 2019 year so last year there were 58 points available and the ACO earned a score of eighty two point four percent And so here's where I made a mistake So of the 16 measures that were carried into the 2019 program improvement was noted in 14 of those measures not 12 So there were Three measures where a decline was noticed and it was very minimal Those were in the timely care appointments and information caps composite the Caps stewardship of patient resources and risk standardized all condition re re-admission And I just really want to stretch how minimal the declines for and I am working with the MMI to see if They did any statistical significance testing on those results to see if there really is truly a statistical difference in those scores Something to just quickly talk about in terms of Medicare Most notably kind of the exogenous factor here of COVID-19 and the public health emergency Really impacting some of the ability to score Appropriately for the 2019 year in addition we talked about this with the growing provider network and payer churn And then for for Medicare specifically the Vermont population demographics, we know that we have an aging population and that Acuity and disease burden within that aging population is higher and These are just sort of caveats that we're looking to see if have we're looking into more detail to see how these might contribute to our overall results And last but not least back into my GMC be hat I really discussed some of this had nauseam already, but GMCB staff In the near term are going to dig into the impact of ACL payer quality outcomes on our states to be 19 quality performance under the model And we'll certainly be bringing those insights before the board again likely early in 2021 We'll be working to untangle year-over-year quality performance from changes in metric student increased scale or changes in the population And per the 2020 budget order the ACO and the GMCB staff are working to develop a dashboard that include ACO and HSA level quality results over time and For the GMCB staff are creating and publishing data visualization Cumulative APM quality results and this adds to our existing available resources On our tableau site for things like total cost of care and scale participation Looking forward to 2020 just a couple of things that I want to note that we've heard from Medicare already Medicare at this point is slated to be pay for performance or for monitoring purposes only this is subject to change And then currently the CMS proposed rule Suggest the removal of the caps requirement for all ACOs in 2020 so full credit would be awarded But the survey itself would not be administered So again, this is in the proposed rule The CMS rules don't become final until it usually about mid-November so we've got at least another month until we know about that and Another note is just that Utilization for 2020 we already know is pretty significantly down So we're gonna have a pretty small end here to work with and so just thinking about What 2020 looks like in the grand scheme of you know the agreement and the five-year term? And then just another note that the federal evaluation of the all-pair model agreement includes an analysis of health and quality outcomes across per month as well as at the ACO level over the life of the agreement But these results won't be available until at least 2023 So we've got some time before we would we would see those and our hope as staff is to make sure that we can start to incorporate Some of these analyses a little a little earlier down the line So with that I'm gonna turn it over to Medicaid Amy and Pat if you just want to let me know when you'd like me to advance your slide Hi, thanks Michelle, can you hear me? Yeah, great. Okay. Hi. So this is Amy Coonrod and I'm the director of operations for ACO programs over at diva and I am here with Pat Jones to give a brief overview of The Vermont Medicaid next-generation ACO programs quality performance for the 2019 performance year If you'd like to advance the slide that'd be great. Great. Thank you So 2019 represented the third year of the VMNG ACO program between diva and one care Which as Michelle mentioned earlier involved 13 communities and an attributed population of around 79,000 Medicaid members which was a pretty significant increase in the attributed population from 2018 which was around 42,000 As folks know as a value-based payment model the VMNG program contains a quality measure set and an associated value-based incentive fund Part of the ACO's fixed perspective payment is set aside every month into that fund and after the performance year that Is distributed to the network based on the ACO's performance on the quality measures that you see up here on the screen For the 2019 performance year the equivalent of 2% of the total fixed perspective payment for the ACO from diva Was set aside into this value-based incentive fund That percentage has increased every year since the program's inception I'll just give folks a refresh that in 2017 the value-based incentive fund 0.5% of the fixed perspective payment and in 2018 it was 1.5% of that payment that was set aside into this fund After the performance year the quality performance is calculated at the ACO level and then a proportion of the incentive fund is Distributed to one care's provider network based on its performance Half of those Undistributed funds that are left over are reinvested by one care in quality improvement initiatives at the ACO level And the other half is returned to diva during the financial reconciliation On this side specifically as a reminder This table contains the ACO's quality measure set for the 2019 performance year of the VMNG program The set contains 10 payment measures and three reporting measures one of which is that CAHPS patient experience survey These measures were selected to align as closely as possible with the quality measures for the ACO's other payer programs As well as the overarching all-payer model quality measure set But there are differences as Michelle's beautiful crosswalk chose To ensure that the measures are appropriate in the VMNG program for the Medicaid population Next slide, please So in terms of scoring there are a total of 20 points available for the 2019 performance year And each of the payment measures was weighted equally within the set and was scored individually Where possible one care's measure results were compared to national Medicaid benchmarks, which were available for eight of the 10 payment measures in the set If Medicaid benchmarks weren't available at the national level or multi-state level The 2019 results were compared to one care's performance on those measures for the 2018 program year Which was the case for two of those 10 payment measures Beginning with the 2018 performance year as well and continuing into 2019 One care was also able to start earning bonus points for each measure But had available benchmarks or demonstrating statistically significant improvement over their prior year's performance I went through that really quickly, but I would like to now turn it over to my colleague Pat Jones Who will speak more specifically to one care's actual 2019 quality performance Great, thank you Amy and good afternoon to everybody So I'm going to give a high-level summary of the ACO's performance in 2019 and then in our last slide I'll really dig into detail on how they performed on each of the measures So for 2019 the ACO's overall quality score was 95% for the 10 payment measures and that compares to a score of 85% in 2018 as Amy mentioned there are eight measures for which we had national benchmarks and for three of those measures One care's performance succeeded the national 90th percentile and we tend to think of 90th percentile as The highest achievable benchmark. I mean that that's a very high level of performance So that was the case for three of the measures There was one measure and that's the developmental screening and the first three years of life measure where there is no 90th national percentile The measure comes out of Oregon and it's used widely by CMS and by many states But the highest published benchmark we have for that is the 75th percentile and in the case of that measure One care's performance succeeded that national 75th percentile for another measure One care's performance was between the national 70th and 90th percentile for two measures their performance was between the national 50th and 75th percentile and then for one measure it was between the national 25th and 50th percentile and I'll get into detail on which measures fell into which category As Amy mentioned national benchmarks were not available for the remaining two payment measures So in lieu of that one care's 2019 performance was compared to their 2018 performance and for both of those measures performance improved in 2019 for five measures in this set there was statistically significant improvement from 2018 to 2019 and that includes one of the measures one of the two measures for which there was not a national benchmark So Michelle if you could advance Great. Thank you. So I want to start with the key Because this describes How points are assigned for performance for each of the measures So for measures where performance is equal to or below the 25th percentile No points would be awarded for measures between the 25th and 50th percentile A half a point would be awarded above the 50th percentile one point above the 75th percentile one and a half points with one exception Which is that measure the developmental screening measure where there is no 90th percentile in that case They were awarded two points for performance above the 75th percentile and then above the 90th percentile also two points We don't we don't put our measures into domains the way that Medicare does but I do want to note that the measures Broadly follow some of the areas the high-level goals in the all-payer model So we have mental health measures. We have two of those out of the ten measures We have three measures that speak to treatment for substance use disorder We have three measures that speak to Treatment or really in the case of these measures. It's heading into the territory of outcome measures for chronic conditions and then we have a couple of more preventive care type measures as well so if you look at the At the table What we've shown is a brief description of the measure the numerator and denominator We show the 2019 rate and that's where the key comes into play. That's where we show You know this the scoring the 2018 rate is provide for reference When we have national benchmarks, we provide those at the 25th 50th 75th and 90th percentile we then show the points that are awarded for performance and then bonus points awarded if there is statistically significant improvement So the first measure is 30-day follow-up after discharge From the emergency department for alcohol and other drug abuse or dependence for that measure The ACO was in fact Above the 90th percentile benchmark It was an improvement over the 2018 rate and in fact It was a statistically significant improvement so that Resulted in one bonus point a companion measure to that is the 30-day follow-up after discharge from the ED for mental health and Again in this case the ACO Performed an access of the 90th percentile. It was an improvement over 2018 but it was not a statistically significant improvement and so there were no bonus points for that measure The third measure is adolescent well care visits This is our measure with the largest denominator by far in this case the ACO's performance was Between the 50th and 75th percentile and so they were awarded one point for that performance It was a slight increase over 2018 but not enough to achieve statistically significant improvement The fourth measure all cause Planned admissions for patients with multiple chronic conditions. There are nine Chronic conditions outlined in this measure so people with two or more of those chronic conditions are considered as eligible and It's a risk-adjusted measure that looks at Whether there are planned admissions this is a measure where a lower rate is better And and so in this case the ACO did See improvement the rate went down from 2018 to 2019 This is also a measure where we have no national benchmarks. And so in this case even though the ACO improved it was not a statistically Significant improvement and so they were awarded one point instead of two points for their performance on this measure The next measure. I've already talked about this is a developmental screening in the first three years of life This is the measure that does not have the 90th percentile benchmark the ACO's performance is You know quite a bit above the 75th percentile it also Represents a statistically significant improvement from 18 to 19 so they Attain the two points for performance and the additional bonus point Diabetes hemoglobin a1c poor control. This is one of our chronic illness measures It is considered an outcome type measure. This is a measure where also Lower is better a lower number is better on this measure. And so once again the ACO improved from 2018 to 2019 the rate was better than the 90th percentile and The change was statistically significant. So in this case again two points for performance and the additional bonus point Hypertension another chronic illness measure controlling high blood This measure the ACO performed between the 50th and 75th percentile This is a measure where there was a slight decline in performance from 2018 to 2019 not statistically significant. So they did not lose points for this as As a result of their performance they achieved to one point Initiation of alcohol another drug abuse or dependence treatment This is a measure where the ACO performed between the 25th and 50th percentile This is a measure that you know, we've been working on intensely in Vermont. It's a challenging one Because of the ACO's performance on this measure, they received only a half a point and the companion measure to that Michelle mentioned this in her comments, but Some payers look at this as a composite in our case. We look at this as two separate measures and It looks at after sort of the initiation Visit that's the person receive at least two more visits in the next 34 days after a new diagnosis of substance use disorder and So in this case the ACO's performance improved from 18 to 19 And it was a statistically significant improvement. So they got the bonus point their performance was Between the 75th and 90th percentile and so they got one and a half points for this and Then screening for clinical depression and follow-up plan This is a measure Where again the ACO improved from 18 to 19. It's also a measure where we don't have the National benchmark. So we looked at change in performance over time This was a statistically significant improvement. And so they received two points so the the total points with the Performance points and then the statistically a significant improvement Resulted in 19 points out of 20 potential points So that was again an overall performance of 95 percent. I just want to say, you know from our perspective This is strong and very encouraging performance to have this many measures Above the 90th percentile above the 75th percentile seeing this level of improvement from year to year These are really encouraging results and I think reflective of the Really hard work and good work that providers in Vermont are doing on behalf of Medicaid beneficiaries So that that does it for our presentation and thank you very much for your time and interest So it's not Andrew I'm going to turn it over to you Thanks, Michelle. Can you hear me? Okay. Yes great, okay my Screen is not synced up with my audio here, but I think it's working all right So hi everybody, I'm Andrew Garland of the vice president of client relations and external affairs from Blue Cross to shield of Vermont I have to admit I'm somewhat pinch hitting today This isn't my area of expertise But the person who would normally give this presentation is unavailable today joining me is Micah Devers one of my colleagues He's in our quality improvement area He's really an expert in these measures and Micah agreed to join today in case you have Detailed questions. So I'll take us through the high level and then We'll see where your questions go So with that Michelle, I think you can just turn us to the next slide And I'll start just by saying that this is really important to us And I I'm thankful to the Green Mountain care board and to Medicare and Medicaid and all of the folks on the line today for that for the dialogue The all-payer model and the work that the ACO is doing is directly aligned with our mission and our vision For a healthier Vermont and a healthier health care system for Vermont. So thanks everybody for this dialogue I'm I'm excited to be talking with you today So I thought as a next step on the next slide Michelle We can talk a little bit about what our program looks like in 2019 These are just some of the high levels and I'll flow down on the quality Aspects of the program. So this is a qualified health plan program in 2019 You probably know we had a pretty dramatic expansion in 2020 bringing a number of large clients into the program But this analysis of course predates that the basic financial arrangement in 2020 was shared savings As Michelle showed in her great slide our our metrics are a subset of the larger set And we selected metrics that really resonate for a commercial population As others have noted that, you know, the needs and challenges of our population a little bit different than those that Medicare or And Medicare are facing Medicare and Medicaid are facing Our program works in a slightly different way. We we ask one care Vermont to set aside every year Dollars that equate to about one half percent of the total cost of care And then they either distribute those dollars out to the providers in their network or they retain the dollars to reinvest in quality program depending on Their achievement on the scorecard each year so four points they achieve that that frees up dollars to To distribute out to the network and for points that are missed those that share of dollars or the dollars that correspond to those points Stay with one care to be reinvested in next year's quality program I said the idea is whether we're hitting the measures or Missing them or you know not hitting them as hard as we want either way we're reinvesting in the network's ability to deliver quality improvement to our members We do have in our contract some collaboration requirements so And we really try to stay close to one care as they're doing this work We recognize that Blue Cross Michelle of Vermont is a very important supporter So we we pay close attention to what's going on and and we ask it every step What can we do to help and then I'll just note that there was a pilot program going on in 2019 actually continues to this day With the University of Vermont Medical Center as our first ASO client to be participating in the all-fare model With a relationship with one care Vermont. I won't be reporting on those results today That's a very very small pool and I don't think we would want to equate their results with the QHP and Reporting on them independently. I think it's not going to tell us much just because the number of members is so small Okay, and then on the next slide this you know before we dive into the details I thought it was just worth reflecting a little bit as Kelly did when she made this update last year on What some of the bright spots and and challenges are that we face when we look back at the 2019 Arrangement with one Karen some going forward You'll see I snuck a 2020 on there at the end of the challenges because I have the light space to do so Maybe most important on this slide are those first two bullets under bright spots And really taken together to meet they They say that the Blue Cross team and the one care team have a great collaborative approach to doing this work You know if I if I look back at this arrangement, and I've been working on payment reform in Vermont since I started On on the payer related work, but our provider related work back in the mid 2000 You know, I would say that up up until two or three years ago Most of our work in this space could still be characterized by the word negotiation you know when we've worked with the ACO or other provider organizations before this the tone of the conversations in both directions was really was really Dictated from a contract a contracting point of view always negotiating On behalf of our organizations, but I feel like in the last year or two with with one care we have really moved past that dynamic and Foster the new dynamic that that would be better characterized by the word Regulation and as we've encountered a number of challenges sort of external to the program But the challenges that nonetheless has impacted the program the most obvious that you know being the pandemic We've been able to respond together Quickly and in virtual locks up in a way that I just think we've been able to do four or five years ago So that's really remarkable. It's extremely strong base to build from another really great Accomplishment for us in 2019 though, it didn't technically go live until till April of 2020 Was the work we did together to build the first commercial prospective payment system Sorry about that technical prospective payment system and one of the first that we know of of its kind in the nation And that was a really a really challenging Undertaking particularly on theology side and we're really thrilled with what we accomplished together On the challenges side again, I would take those those two bullets the first two bullets together I think they're they're largely saying something very similar Which is it it's still difficult for us to look at all the data that we have on our members and clearly Distinguish the line between those that are in The one care model and those that are not so, you know one of the challenges of using this This type of quality Scorecard program is that it is it's not as directly tied to the work that the providers and the folks at one care are Doing every day as we would like and these are pretty bottom-line measures and There's an awful lot of things that can affect them Between the work that the providers are doing and the time that we actually getting or get around to measure this Well, you'll see I snuck a bright point in there under that first challenge We've already worked with one care to come up with a new approach to our scorecard program for 2020 So that we're not relying so heavily on Measures which are so far downstream, but we'll have more built into the program that really allow us to see one cares work plan and You know look more closely at the results that are coming directly out of their actions So that's pretty exciting stuff. And then a final point You know, I heard the oh Michelle makes this point which is talking about the Medicare program COVID-19 a major disruptor both on our ability to measure quality results But of course as we move through 2020 and into 2021 A major disruptor to providers and their their ability to engage with us on any new Quality improvement initiatives, whether they're through the all-payer model or things that Blue Cross and Sheila Vermont would be working directly on so I think we'll obviously have a very different discussion when we're together next year to look at the results of 2020 Okay, so let's oh right a few other things I wanted to point out There were some really exciting collaborative Initiatives that we worked on together in 2019 and some more that we have underway in 2020 I mean the the two most Exciting for 2019 here on this page One was us really working differently with one care to try to provide to them Actionable practice level data. There's a rather than relying only on high-level data extracts Our our quality team package some information to make it easier for them to serve out Things that they could be given directly to the provider population to help move the needle both on the mental health substance use disorder side and then also As you'll see and data related to some some of the quality metrics on the scorecard And then we also started working with them in 2019 on a really exciting program That's a little bit aside from the quality Scorecard or much higher up to get more folks into primary care One of the things that our our quality team and our nurses work on all the time our intervention is designed to Find those members on our books who are not accessing their their primary care physician services Regularly trying to make contact with them and encourage them to go in and use Those preventive benefits that are available to them So in this initiative We've worked with one care to try to move some of that communication and encouragement From Blue Cross Blue Shield of Vermont directly to the primary care physician office with the idea that people are more Likely to pay attention or respond if they're getting that encouragement directly from their physician So that's pretty exciting work And then on the next slide I just listed out some other chronic condition Some other chronic condition management Initiative that we had conceived and begun talking to one care about even before the pandemic and you'll you'll see that They all involve some some form of telemedicine or telemonitoring so You know, we're encouraged that these are initiatives that will be able to continue to pursue through 2020 and 2021 even in the face of this very different Pattern of utilization that we're seeing across, you know across Vermont because these still involve our telemedicine or Telemonitoring so they think that can go on even in the absence of the same kind of in-person care that that we are used to seeing before the pandemic So I deferred a big finish here a lot of expense to the actual scorecard So our our scorecard has just nine measures on it that are considered for payment So these are the nine measures that affect that half a percent that one cares set the part as Michelle indicated at the beginning of The presentation we also look at a number of other measures caps measures primarily those are reporting only measures You can see here that where we've indicated a check mark one care Achieve full quality measures on on on a particular measure and they did that by Exceeding that national 90th percentile that Pat Mention and we did make a change to our program in 2019. I believe So that in order to achieve full points on a measure Even if it's a measure that's as tough as say That initiation engagement of alcohol and other drug dependence treatment where our starting point is way down in you know Below the 25th percentile or around the 25th percentile in order to achieve full point They have to get to the national 90th so and one care was was willing to take on that challenge really to recognize that We we shouldn't be satisfied and say that we've fully accomplished What we needed to accomplish on any particular measure until we're the best in the nation Our program also allows them to earn some bonus points for having statistically significant improvement in at least two measures Or in any particular measure and they did that on two measures last year So I didn't indicate this on the slide. I'm not sure why I apologize They earned 14 and a half points out of a potential 18 because of those bonus points which I I think equates to about 81 percent of potential points and you can see you know measures like that Initiation engagement of alcohol and other drug dependence treatment You know, it's a long haul for us to get that up to the national 90th So we would we would not have expected them to get to 100 percent. That's a that's a really really high bar to accomplish But still the way we've structured the program the Dollars that don't flow back to the provider network again remain with one care to reinvest in work on those measures that that aren't at the national 90th This year another thing you probably notice on this slide can be jumped out There's you know, the ups and downs. I think it's important to keep in mind that even though this is a fairly large pool It's still a fairly small pool. So The denominators on some of these measures are are relatively smaller I think are going to be significantly smaller than what we would see either in the Medicare pool or the Medicaid pool So we would we would expect more ups and downs and then I did take a few minutes and look back at the I Looked back at the 2018 Scorecard just to remind myself and so the point system was a little bit different The the overall accomplishment is pretty significant. We had three measures in 2018 that were at the national 90th statistically significant improvement in a couple of measures and then a couple that that swung in a different direction. So You know consistently good work here and we're we're really optimistic about You know continuing to evolve this this quality program in 2020 and and beyond as we we move into this new approach That takes more of a work plan Approach and and the scorecard is de-emphasized a little bit. We'll still of course measure all of this stuff You know, that's extremely important, but moving the payment The payment part of the program to be more directly tied to the transformative work Will be a really interesting experiment and we're thrilled that one care was willing to go there That's all I had. I'm not unlike Pat I can't take you through these measures one at a time But I think she covered all of them in her slide. So thank you Thank you, Andrew. So with that, I will turn it over for to board questions And you've got the full panel here including Tyler from one care to jump in and answer any questions that you might have for For them as well or any questions that us payers can't can't So I'll start off Pat as really the The mother of the quality measures in the state of Vermont. Is there anything that jumps out at you that is Alarming you No, I don't think so I do think that you know, you're seeing where some of the challenges are you know Creating in particular and even engaging people in Substance use disorder treatment is a real challenge And I'm sure there are multi faceted reasons for that that have everything to do with them, you know Capacity geography But you know, those are even the engagement measure where we tend to do well If you look at the absolute rates Both for Vermont and nationally, they're very low and so just continuing To work in those areas where we You know where we know that treatment helps and Just and we've done a lot in this state in terms of access to treatment and types of treatment But you know that continues to be a concern You know on the plus side seeing some of the improvements and you know, some of the outcome measures like the diabetes for control measure And just seeing the across the board Improvement and the rather high level of improvement anything above 75th Percentile is strong performance. And so it's really again. I just want to say it's a reflection You know, certainly of the work that people have done together the ACO payers You know aligning measures, but also The providers really doing the hard work of quality improvement That to me is very encouraging So I saw much more to be encouraged about than to be alarmed about Any questions for members? I had one question for Pat as well when you look at the The quality measures where we were saying, you know, the achievement was I think 19 out of 20 but When I look at it, I'm looking at it was like 15 out of 20 and then there were four bonus points So how do we How do we look at that because wouldn't that really be there were 24 possible points? You know, there's more than that, but they achieved some bonus points So it's you know, they there was 15 out of 20 and then they got four of the bonus points So even if I said it was, you know, 15 out of 24 I just want to make sure we're reflecting, you know The right percentage of how we're doing and and obviously we're making improvements in a lot of places, but Just wanted your reaction to that Right. Um, you know in keeping, you know, the idea of the bonus point was to allow them to earn more We did not change the denominator. So if you look strictly at performance It was 15 points for performance. I will note that That if they had statistically significantly declined They could have lost Some of those bonus points as well, but there's no question that was an opportunity to For them to increase the score. I You know, I was I I think we were pleased and surprised at the level to which those improvements were statistically significant because that's a you know reasonably high bar Yeah, I'm not trying to panelize. I'm just trying to look at it Yeah, you know from from different ways of the math. So thank you. Yeah So I'm just kind of looking and slide 14, you don't have to go there but it's The verbiage was that of the 16 measures carried into 2019 Improvement improvement was noted in 13 measures And I'm just wondering what what does improvement mean? Because when we get down into Medicaid and I have a question there, but Medicaid they're talking about statistical significant differences And in Medicare, it's improvement was noted. And so I assume that's on that 90, you know percent on that percentile and was there a spread that was assumed that if if if if the Measure increased by a certain number in the spread It would it would be considered an improvement Yeah, so for Medicare We do not yet have the statistically significant analysis done From our federal partners. And so that's something I'm waiting on So like I said in those measures where we did not see an improvement and we saw a decline in the score It's so minimal in so many cases that we're I'm not sure if it's statistically Significant or not and the same goes for the the noted improvements There are some where I could make an educated guess and say that I think that they would have statistically Significantly improved just based on that sort of gap But without that analysis, I'm not comfortable in answering that on their behalf Once we do have that analysis, I'll be sure to pass it along to the board and we can certainly do an update to this presentation Unless one care happened to have that and I do not But I do think you know if you just compare the two And see sort of that prior year performance rate and then against the 2019 performance rate But again trying to keep Keep in mind that something that we're working through is taking into consideration those change those massive changes in the scale population And changes in the denominator overall and sort of what impact that has on performance okay, and then so looking then at Medicaid and It's a you know five measures. There was statistically significant improvement and there was the point at the bonus point approach, but what can you talk a little bit more about what? statistically significant Means in that context. Well, I mean, what is the hypothesis that x caused y and And so there is a spread in the numbers But is it just the fact that it's associated with the ACO or my phone's ringing in the back? I'm sorry I Don't know if you can hear it, but So I just if you could have a few more sentences about I mean You know how how can we be assured that the statistically significance is aligned with these measures in the ACO program? Yeah, thank you Tom. I you know, I think all we can say when you're looking at statistically significant improvement is all you can say is You know the measure improved And probably at a level that was not due to chance You know what the factors were in that improvement? whether we're reaching level of alignment of measures and a critical mass of attributed folks That you know that that provider that allows providers to really focus on this. I don't know that we can say that But you know to have um year over year improvement Is statistically significant? It seems like we're really going in the good direction. I mean most of our measures improved we saw improvement But half of those payment measures saw improvement as statistically significant level You know, I think as michelle said there's a lot of digging into as to the why and how to capture this but Directionally things look look good at this point Yeah, I would agree that I mean the flow is in the right direction Um, and we have two or three more years at least within the all pair model to kind of Continue to track this and learn more and and have more data. I just I just you know Because of some of the controversy around the ACO Um aligning and linking these quality improvements and and this positive flow to the ACO. I think is an important um consideration as opposed to saying Some of the Medicaid numbers are better because over in the education department, you know for kids on Medicaid They improve nutrition, you know, and it's kind of like, you know in a different arena. So Uh, you know, it's it's the obviously the direction Um You know in a positive way and that's a good The um final final thing is uh For blue cross blue shield now that blue cross blue shield is um engaging with the ACO I I wonder if um And I could be totally off base on this but but to me the benchmark plan for the qhp population Hasn't been kind of reconsidered Since its inception, which I think is in like 2012 or 2013 was the basis for that plan and and uh one of the areas for example that we see here is diabetes and one of the areas You know in the um benchmark plan is diabetes, but there's no organized program in the benchmark plan to uh Avoid the diabetes. There's no organized pre-diabetic program. And I'm just wondering if blue cross blue shield might kind of uh Urge the aco and other Um partners and participants To revisit that benchmark plan in order to make sure it's as aligned as possible With the goals of of the quality goals that we're talking about here Um, I you know, I do understand that some who were there when the benchmark plan was first crafted that it was kind of a food fight with everybody trying to get their you know their their um uh service Engaged but you know, I I think you know folks can say there's a limit here We're just looking at prevention now in terms of the restructuring of this benchmark plan And uh move forward in that regard Yeah, thanks. We we have Introduced some optional plans that are really focused on some of the issues that you um that you described tom but I I'm sure the folks on on our team who are working every day to to um design benefits would Would be thrilled to sit down, you know with other stakeholders and look again at the benchmark designs and ask, you know You know now that we know what we know Um where the network is able to engage how can we do this? How can we do this better or differently? Um to make it easier for members to make those connections and that that's a The question that's on our minds all the time in fact, I have a task force working on this This question of why why why are people not taking advantage of zero cost share services? Uh, which we know they need and and we tell them they need and they acknowledge and still say well We're not going to go because we're worried about cost. So I think those are really important issues and and um, I will absolutely pass that engagement along Thank you Other questions from the board Hi, this is robin. Um, I had a follow-up question for andrew related to The work plan approach. I was interested in hearing a little bit more granularity about how you're thinking of approaching that and um Uh, just maybe giving a couple of examples about how you would use that for the quality measurement Yeah, well, I will admit that we are still working on the specific So if I don't offer them, it's not that I'm being evasive, but the the idea is that instead of saying You know, let's let's move the money around based on the results for adolescent well care visits We want to move that question upstream a little bit or downstream I guess depending on your perspective and we start by asking the aco Okay, well, what are the plans for 2020 for 2021 to move the needle on adolescent well care visits? Let's show us that work plan and let us Let us sit down together and agree on a point structure That is tied to some of those activities that you specifically hope to to put in place And let's find some measurable Between the work and the very very sort of downstream quality measure To see if we can get a better sense of how the action Is is turning into results because to tom's really good question and pass great answer It's hard to tell. I mean this as as everybody knows there are so many dynamics at play in this healthcare system And you know when you push on something Whether or not the thing that's you know 15 dominoes down the down the line actually falls can be really hard to Know, you know did it fall because of that push or did something else come in and and influence it So so that's the change we're trying to affect there. I think we'll have a better sense Over the next couple of months what that's going to look like specifically But we were we were really thrilled that the DACO was open to making that kind of change Yeah, it sounds like an interesting approach because I I do think one of the challenges as we've talked about is And that's pat alluded to when referencing Scale is that the quality measurement results here at the individual provider level and so There could be a lot of different things going on in an individual provider's office that may Effect those So that's interesting I guess the other question that I had that I just wanted to ask The diva team and the blue cross team is Based on the quality measurement in In 2019 Where are the areas that you think? It's most fruitful to focus on moving forward in the quality arena given all the dynamics around the different areas I'm just curious if in your opinion on that I'll start with that. This is pat I you know, I think I alluded to it earlier, but I think continued work In the substance use disorder treatment arena Is is going to be really important you know and and partly because it It it rolls up into the tragedy of deaths from drug overdose and other morbidities from substance use disorder, so You know given and it's a challenge. It's an all hands on deck Approach it's not that we can expect the providers to do this alone It's not that we Can expect the state to do it alone the payers to do it alone This is a multi-year all hands on deck effort And it's one of the really unique elements of our approach to quality, which is that you know, we're looking at areas that are you know, it's hard to to improve in silos They involve public health efforts as well as clinical interventions and having capacity for treatment and And giving people the support they need to get treatment, but to me again when I Look at the at the results were That's an area that I think we've been working on and that we need to continue working on Yeah, this is Andrew from Blue Cross. I'll I'll answer pretty similarly I mean if you look back at our list of of nine metrics, there's nothing on that list that isn't Super critical. I mean, this is all really really important stuff You know more than 60 of our population is living with a chronic condition So, you know, the diabetes measures the hypertension measures These are critically important to us But like pad I mean if you force me to just pick an area focus, I would say the mental health substance abuse Disorder challenges are so huge We know and are learning more every day about the number of our members with chronic conditions Who also have Cohen co-occurring? Mental health or substance use challenges. These are so often undiagnosed or under diagnosed under treated So, you know, the more we can do to support our primary care positions And others in the providers them To focus on those to understand, you know, where they're occurring how they're affecting the course of treatment I think that's just really really critical stuff And and an area where as a community We just have so many opportunities to make advances. I would ask Micah who's also on with me today If there's anything he would add from his perspective as a as a real specialist in quality improvement Andrew, I would agree with everything you just said and in line with Pat said as well I mean we we see this in the acl population But yeah, just to underscore, you know, as we look at data across our book of business There's a real member need in that arena So yeah, I don't think I have anything beyond that thing Thank you. And Michelle, I will not put you on the hot spot because I don't think you just speak to Medicare The opinion on this because we probably don't know what they would say But if you had any thoughts, please feel free to weigh in Sure, I would just you know, not I will not speak for Medicare Although, you know, we've done some initial digging into the Medicare Rate and by we I actually mean GMCB staff not Medicare Great and and we know that for Medicare in particular some of those substance abuse measures are more heavily weighted to alcohol abuse In the older population and there's a you know, there's a fairly large stigma with with accepting treatment among that group and so just looking into You know, basically I agree with everyone else at the mental health and substance use kind of piece of this is is big and As pat noted during her presentation when we look at national levels, you know, the 90th percentile is Considerably low performance rate. So even you know to get up to the national 90th percentile you're talking, you know 20 percent it's It's pretty low. And so just working through Sort of ways that, you know, all of us together can can come together to offer these services and In a way that is accessible for for all over all Vermont's population. Not just You know, those who might have better insurance coverage Thank you. I don't have any other questions Other questions from the board Yeah, this is Jessica here and first of all, I want to thank you all for the presentations I really really appreciate the optimism and the hard work that providers have obviously done to to Create some of these improvements as well as the work by the payers and the aco I want to make one casual observation that is just Building a little bit on the last conversation that we've just had about mental health Abuse and I would say it's a little worrisome for me to see some of these levels You know around mental health and substance abuse at an absolute level so low Even though I recognize that's also national In particular because of the current climate that we're in I think that covet as I think we're all probably realizing Uh has created some enormous Stresses on all of us in terms of both mental health and substance abuse. We know that people are drinking more There's data coming out about that. We know that mental health conditions are Are even more concerning as people are quarantining as they're trying to juggle child care and stress and all of the things that that covet has done So I guess I just want to throw that out there that bringing up these measures is even more important than ever I'm working towards uh doing that and at this time at this particular time In our state's sort of history and the other thing I would just throw out there is Influenza vaccinations among the elderly and the medicare was was at the 70th percentile And I would just also add that that's a little bit troubling to me given that we know The impact of flu and covid simultaneously Um And the other one the all-cause unplanned missions for those with chronic Conditions being at the 40th percentile again Folks aren't going to their primary care doctor. They're reluctant to seek care. So these are all when I saw these I thought oh goodness. We really need to work on these right now even more so than ever Because of the current climate that we're living in the stresses and the and the conditions that people are living under So that I just want to throw out there as an observation Um more about the current climate and the need to do this important work Uh, Andrew, I wanted to tell you I really appreciated the collaborative spirit With which you you know in the ways that you were presenting and working with the aco and the new initiatives to put more actionable data in the hands of practices And trying to link aco action steps to results. I think that's really important And I just was wondering this is maybe a question for you andria, but also for medicaid Are there any analyses that your teams are doing by hsa? Along these quality metrics and if so, are there big disparities between health service areas and what can be done about it? Or is that something that we're also unpacking? Obviously, this is all aggregated But thinking about specific areas of our state and whether there's more work specifically more work to be done Um In those areas if any both of you could speak to that and a pat and andria could speak to that And I won't put you on the spot michel necessarily because again, you don't speak for medicare But again feel free to add about Disaggregating by hsa Yeah, thanks. That's a great All right, i'll go first actually i'm going to turn it over to michael and ask him to give us a little more insight into how we segment this analysis At this school is pretty small and I think it would be difficult for us to cut the You know the aco population by hsa, but I don't know michael. What do you think? What have we done there? Uh, yeah, so I would agree with that when we look at our qhp population It's pretty small within the aco and I think that's one of the real value ads that the aco can bring to the table In the reports that they give us just you know showing how they break it down by the health service area Yeah, and I was going to respond very similarly That you know we we do um do the analysis at the aggregate um level We aren't digging in at the health service area level But I believe that the aco is and would agree that that's a um, you know, that's one of the values that they bring So just I will only elaborate and just kind of respond to your initial Thought process on on addressing some of those measures. So not as medicare. Um, but I think you know at part of The other work that we're doing in the state around telehealth and um those types of services I think part of What we have to think about moving towards 2020 is how do we capture that type of information because currently The way that the claim system is set up and that heat is to set up a lot in a lot of cases Those types of things aren't captured and so how do we start to think about that and then even potentially run some of You know new run newer analyses on older data to see if An impact in some of the numbers that we're seeing in those performance rates And that's something that we've been thinking about with our analytic partners to see if we can kind of get a better handle on that As we sort of expand these offerings across the state Great. Thank you. And I guess my second question is I know that um CMS suspended the caps survey And that's obviously out of our control But I do think about patient experience being really important to understand And I'm just wondering have there been conversations about trying to do something within the state to substitute To reach out to Patience as a check-in. I recognize that, you know, you're not going to be apples to absolute apples, but But Any effort any thoughts about how we still continue to assess patient experience in the model That we do have The blueprint still runs their pcmh survey for the list of pair and we do see Medicare Through that pcmh Caps survey and so um one of the questions that is was Telehealth and Post is For each of those And we might have to rely on not this year not Moving into the 2020 Everything right now is pointing towards the that will be comfortable and that will be required But it should that become the case. I think we will have to follow more heavily on on what we receive through the blueprint And yeah, that's We like to look at it. Uh, and also my pair and so it's something that we can certainly Use in the end But in addition, you know, I think as we enter Thank you budget process for 20 That could be conditions that we have There Thank you Karen, I think you're muted Yes, uh chair mullen is uh, okay if I respond to that question as well Sure Yeah, I just want to reinforce what michelle said. We actually have a pretty nice setup With the blueprint because they try to obtain Patient experience results using the caps pcmh survey Um, and they they do it at the practice level because the idea is to give practices some actionable information and so it goes out to a large number of our mentors and then We are able to get the results By a Attribution and so so for medicaid we get um, you know any respondents from a part of our attributed population We get rolled up results for and as uh, amy mentioned early on That's a reporting measure For the medicaid program For the quality framework Yeah, I'll just add to that pad so for care the survey The cap survey is a set number of surveys. I believe it's 860 Tyler you can correct me if i'm wrong That's a sample that's every year and the response rate is pretty low on that. I think in this past year the most um, you know the highest denominator was In the high 200s um out of all eight hundred and sixty for the pcmh survey that sent to about 52 000 brahmanters and so that one gets it's a It's got a huge response rate, but that pool is much bigger And so you kind of do get a little bit more detail on that as part of the thing Great. Thank you both Okay, if there's not any more further board questions, we'll turn it over for public comment Does any member of the public wish to comment? Uh, mr chair This is Susan erinoff from the um brahmant developmental disabilities council So first of all, I want to thank you and your staff and everyone who participated in um having this hearing and for the The uh data and the discussion. I think it's the best ever No, I interested in ACO quality results for more years than I um, we all probably care about Um, the brahmant developmental disabilities council is very interested in these results for one really simple reason The experience chronic conditions better three times the rest of the population people with disabilities in brahmant are the largest health disparities group our department of health is tremendous in job diamonding that sometime, I hope the green mount care board would have the time to um having It was tremendous That said um, I want to revisit and maybe get to date on an issue that's come up or I had a discussion about the lack of Use disorder measures was great and I just want to bring to people's mind and I think um Maybe it would be possible during the reboot or during the negotiation situation to add to the things What can medicare do in brahmant to help make this better? They could allow our designated agencies or other agencies All of our agencies all providers could build medicare For the same licensures that we bill medicate to provide the services people better than me people at adab Charles Guernsey and Inarticulate this issue, but there's a barrier. There's a workforce barrier and it has to do with There and it has to do with medicare Unlicensures licenses Decade pays so Maybe that's the thing that Um in terms of access force and in Um, so that's a possible solution Um People at the department of health they know this they've documented it the information's there There's an Getting um It's out there it's known about and I'd like to move on and if it's possible through you mr. Directly I did have a question or two for blue cross And um for medicare And so the question for blue Is that four of them? I think it is measures decline And one of the questions I have in general and it'd be for pat nurse staff everyone tyler Is why would some measures decline in blue cross? And increased in Medicaid if this is about how payers are paid and not how services are provided So that's kind of a more it's a tariff question, but I was wondering if andrew I don't see um if andrew could address the declines in Specifically in the blue cross So that's one of the things that I wanted to ask you to do is I think we're going to do a little bit more of a payment um having to do um chronic Sure, are you all right? Can you hear me okay? Yeah Go ahead Thank you. Um Yeah, so uh one of the Note I read that slide pretty quickly, but you'll see that that um there is a note there Sue on the second bullet Small populations even the a large one follow up after hospitalization for mental illness, which Dropped quite a bit. Um, I look just at the absolute numbers. None of these are statistically significant minds. So, um You know that and say you know what we didn't make it, but it doesn't appear that I really felt that Of these measures and then sort of to your overarching question, um, you know the Changes that we discussed earlier um about Strictly sort of measure scorecard based approach to measuring program and And tying the results of the the quality payout To a work plan. I think meant to get at Some of what you're talking about. It's really hard for me to look at any one of these measures and to say We're absolutely certain that the improvement um was the result of The positive work of the aco or that the lack of improvement Um was because the aco didn't work. It may be that Places of one care really focused and We don't quite see things falling through the bottom line of And in us is where the focus wasn't as fun Oh, we you know Really tight relationship between As in the outcomes and we're going to keep working on that It's really important to us to understand it. I think it's really the one care as well And as we try to you know grow this program in the large group space the client space talking Our customers about it. It's going to be critically important to them For us to say yeah, we know exactly where this is making a difference We can we can prove it. So the question you're asking is a really good one and and I think we'll have a lot more learning To get a great answer You know as a state employee, I've been trained in the basic real space accountability. Is anyone better off? So how would we know? but Andrew The question that I had the slide isn't here and I don't know if you could do this calculation Is it seems like There was a change from a big Last year from 2017 to 2018 That blue cross is aco quality score went up like from 73 percent to 86 percent Big change up last year But that the overall decline this year From 2018 to 2019 pre-covid Was from like 86 to 80.5 I'm hearing you you're saying That's That decline Is not significant to you And that's what i'm trying to understand Yeah, well, obviously we want to see all these Moving up all the time Um, they're there in the domain of the aco or not So of course, um, you know, are we satisfied with the results? No, that that's why we changed the scorecard methodology And that's an important thing to keep in mind when comparing to 2018 points In 2018 Could get full points on a measure without Accomplishing the national 90th on that measure. We made that a bit harder in 2019. So I think there's a lot of there's a lot of bright things For us to be positive about in this this work that we're all trying to do But if you are saying you look at the scorecard and conclude that we have a long way to Go, um I would agree Like I think that that the efforts that we've we've started are only just beginning And we're gonna have to keep For a long time to bring all of these up to where where we would like them to be ultimately Yeah, all right Thank you So I don't want to take up Time I did I was Medicaid program about the hypertension measure specifically I don't know pat or someone if you could um address that um that score is only a 63 3% is lower Than the 2018 and even lower than the 2017 score. So what I see is a three-year downward for On a very important measure So I don't know if you want to get into the weeds here, but I'm really concerned me You've already talked about I mean this substance use one really really concerned me But everyone else talked about that. So I just wanted to talk about That hypertension. I think it's to you in so many ways Um controlling high blood pressure. It's so important Well, I won't again. I know we're short on time and I won't get too weedy You know, first of all the decline I want to I want to just re-emphasize that it's not statistically significant Um, it's really not a We don't We you know if it's another than a chance But um, I do know both Things like the diabetes measure Um, these are more alch more and in measures as opposed to And as opposed to price like measures. So it's not a question of were they getting Recommended care. How did they do? What was the pressure level? What was the hemoglobin A on C level? And so when you're talking about measures like that, um, you can still Riding the recommended care that doesn't always mean that you'll outcomes. So, um, just want to emphasize that with these types of measures All cause um and admissions for patients with multiple crimes That's another outcome measure. There's a lot that can come into play there as to What the results are some of the other measures, you know It's are they getting the recommended care and those are measures with less variables. So they're tough And you know, um And I'm actually, you know, I'm glad I have Some of those outcome measures in our measure that and I think as you said correctly important that we Um, but that's that's how I respond to that. Thank you. Right. Well, thank you for that You point out something that again is really tied to the The fact that people with disabilities have twice to three times the rate Of some of these chronic conditions including specifically high blood pressure Have a lot of barriers to both accessing care, but also to controlling patients Makes that fear the fact that people are Going to be paid based on these outcome measures and the process Makes that And my new favorite lemon dropping All the real so anyway, thank you for pointing out that outcome part It's one of that is of great to concern great concern to people Um living with disabilities Again, I control the outcome Thank you, sir Comment go ahead My general final piece and then I'll be done. I'd really like to know Andrew and from pat when the financial results This quality results are wondering then the results will be available This is I don't know that I have a specific date. I do know that we're really close. Um, I've seen all the data seen And what's left is to understand My you know, what what influencers were so we're we're really close to having Done and dusted say, you know when when the board and and other ready to get back together again to talk about it And we're in the same present at at the Those to have a final results Okay, the understanding is that one care will need to Those for their budget attention The younger thing So this is michelle Just note that you know last year when we did this presentation it wasn't until And so we had a lot more time Finance Prior This year and I got all ahead of myself was to close at 29 Started opening up another year being Well Look like that to happen and you know sometime during the month of october very likely The end or the beginning of november we will invite the bears back So we'll be during the budget process Talk about the financial results for 2019 Great. I think we all close out 20 Thank you. Yep other public Go ahead deal On the statistically Part of it Whoever thinks they can answer this question And I've made this point before and I will not let go of us. I work too much with data ends How many lives are in a measurement? Minus one That can be a fact before Measurement becomes significant Uh statistically significant I can know the number of lives it takes To be statistically Can Then stop and think of the Of lives Then certain specific populations I can have profound effects on the measure And if that is the smaller amount Then that is a flawed argument Yes, I get it statistically significant in what it is But my populations that can affect that measurement Are a much smaller population Or a very significant population Is much smaller in size and therefore Everyone in that particular population is affected Then I call it a flawed argument Do you see where I'm going? I'm not arguing whether or not in the big picture something is statistically significant