 We believe that we, with Medicaid, started the right cycle, which is Medicaid and a fee-for-service environment had to keep putting on more and more band-aids to try to control a fee-for-service spending by figuring out better ways to not pay providers for care they've already delivered because they didn't get a prior authorization, and we created this as the reverse now of undoing that since we're taking risks, eliminating the burden, and, you know, those sort of things were really low value added in the system. We do develop a set of annually-clinical priority areas with targets to drive focused improvement activities across the whole sort of spectrum of population health management. We do have very advanced clinical committee hierarchies, both at local levels and statewide where doctors and other clinicians do get together to talk about our priorities and things that we should work on. And then, you know, finally, that cycle of last year, which has been an amazing cycle, a lot of work from the board as well, you know, to put in our first annual budget, figure out what's even in an ACO budget, you know, work on a next new rule for a pretty complex regulatory animal of ACOs, and, you know, get our first-gen budget submitted and approved, and then seek the certification that's required for us to be an off-year model of ACO. A couple new things to mention in 2018, partnership with RISE Vermont. RISE Vermont is a community-based collective impact, healthy lifestyles program that was piloted for the last four years in St. Alden's Grand Isle area of Vermont. We are now working with a newly formed RISE Vermont Corporation as a partner for OneCare on what we call a Quadrant 1 strategy. So when we risk score all patients, so part of our goal in OneCare is to help our communities have a game plan for every attributed life, whether they're very, very healthy and well or have multiple chronic diseases or in the middle of a catastrophic episode. You know, the healthcare system, trying to really be a health system, is a hard transition, and so from an ACO perspective, what do we do with Quadrant 1? That people are largely well. They don't have a disease that we need to make sure they're on the right drug therapy or that the lab tests look good. They don't see multiple hospitals and specialty physicians in a year to try to coordinate on them being on the same page. Probably aren't clients of community-based agencies for healthcare. And so really RISE Vermont's our way to get our arms around what does it mean? It really ought to be wellness, prevention, healthy lifestyle, partnership with primary care, the healthcare system, local businesses, schools, community leaders, et cetera. That's what RISE Vermont is, so we are working with them to provide what they did in the St. Albans community as a tool for other communities to deploy. There is interest in a large number of communities to implement that model. And OneCare is hoping to make that possible. Supports and Services at Home SASH program, which basically provides on-site concierge care coordination at senior housing centers. It was funded under the original MAPCP, which is how Medicare paid into the blueprint for health, which was their demonstration project. We channeled some of that money as a state into forming the SASH program. That's part of what OneCare's commitment is to continuity. We now pay that money in lieu of Medicare toward the SASH program. And the more we learned about that model the more we liked it and now are using it as a sort of preferred innovation. So one of the things that we did, based on the SASH and Howard Center proposal, is we're funding a pilot, or the Howard Center, who's the designated agency for mental health and substance abuse in the greater Chippin County area, is sending a mental health professional to do a circuit of visits to the SASH housing center so that the SASH coordinator can get some of those seniors signed up to see a mental health professional in a very easy, no-cost and non-stigmatized way. It should be a really important piece of the geriatric psychiatry and mental health support fabric, where again, we want to get people treatment and ability to access community-based programs as early as possible. Comprehensive primary care reform pilot. So this is what's coming next in primary care and is my biggest answer for how we're going to try to make a simpler, higher and better quality of life model for primary care to do what they really want to do, which is have a great team-based approach to the panel and be integrated into the system on a bigger basis. We've got three dependent practice organizations. It's six sites, because one of the three organizations is primary care health partners that has multiple practice sites. And really, what we're starting to do is take all the fragmented ways primary care gets paid. Fee for service from Medicare. Fee for service from Medicaid. Fee for service from Blue Cross. Out-of-pocket payments from those three payers. From Medicare, Medicaid, commercial, animal payments from one care. Value-based incentive quality funds from us. PQRS from CMS. And start to unify those into one payment stream and simplify it into multi-payer blended application models. Now we don't have all those payment streams rolled up yet, but we did a bunch of them from one care and the underlying fee for service from our three major payers. We are rolling that into what we're testing is a single adult primary care cavitation base rate. And by base rate, I mean a single dollar figure that we can say is fair and equitable across payer mixes that can be risk-adjusted based on is a primary care panel older and sicker or younger and healthier. You've got to be careful on the younger because we do want to have access to child wellness visits and vaccinations and things like that. But we're testing a blended multi-payer model of what do you pay primary care and what is the fair way to do it. And yes, we're supplementing that model even further than the typical add-ons that we're offering in what we call our standard model. But it's really what's coming next, which is how do we think about as a state what is the amount we're setting course for as a percentage of the total healthcare spending we want to spend in primary care. For the CPR pilot practices, it went from about 5% for their trivialized to about 7% in one week. We're not done yet. We probably want to offer to the other practices that were in CPR we want to put in our budget for next year expanding the program because it does, according to these three practices, hold a lot of promise and we're still working out the operational tweaks. The reason why we limited it to these three, or it ended up being these three, was it was a bit of a leap in fate. Those practices had to sign a piece of paper saying we are not going to get paid for service from Medicare and Blue Cross anymore. In lieu of what one care is going to pay us. That was a big deal. And you know, anything that's a pretty major reform does have its operational growing pains and sort of gotten through this together with these three practices. But I believe this is going to be a big get to and early test the model that we want to offer additional primary care infrastructure. So speaking of primary care, really what we're trying to do is build a better model and help primary care to have the resources and the capabilities and the tools to really sharpen their volume further. We've got a lot of primary care practices, whether they're a hospital employee, independent, or FQHCs in Vermont. There is a lot of variability in the way they do their business, in the way they do the population management and the tools that they use and driving some sense of a aligned model across payer mixes and practices. Yeah, that is part of our vision. We try to be very responsive and get a lot of input from primary care into that model. And guess what I'm all primary care physicians agree on. We do our best to facilitate and make decisions that we think help with the outcomes on quality and utilization and alignment in our contracts with Medicare, Medicaid, and commercial that the payers really want us to have a real population management model. This isn't taking risks paying primary care more and hoping for the best. They really want there to be a real model there that they can measure and represents progress as they allow us as providers across the whole continuum. The keys to the kingdom a little bit more in terms of controlling the models we want to implement. Yeah, we want to have more resources in primary care. I really mean it from the bottom of my heart when they say what I've learned over the last four years is that primary care has been asked for a decade to do more without a whole lot more financial resources. I cannot believe how much they do it and how much they maintain energy that they do. Really the idea is let's work on the model that primary care really should be doing. It wants to be doing and let's figure out how to allocate the resources there now. In the absence of major investments from the delivery system reform fund in Vermont we strap our way into doing it so it's basically like I said earlier moving around as we fly the airplane moving around the money so building the airplane while we fly. I think we made a big down payment on being serious about that for 18. I think that will continue and I look forward to the dialogue with the board on what is it we're trying to set a course for and measure in different ways in terms of what is financial resources for primary care and yeah I really do hope that what this means is that Vermont will be seen as a place for those training in primary care near or in Vermont will say that others will come to Vermont as you can get the kind of resources to run and practice the right way and have the same quality of life with a fair salary as a primary care physician. Work to reduce and avoid low value for PCPs that's one of those ones that's easier said than done in an informatics enabled world where healthcare is still perceived nationally as woefully behind financial services and other industries in its ability to use data to deliver value that is a vector that I probably can't bend. There's going to be more desire for more data more quality measures, more structure more measurement that the right thing happens under the right conditions every time and patients don't fall through the cracks. That's the part that I'm very realistic, it's going to be really hard for one care to fight that time because it's bigger than Vermont, it's bigger than us however real low value added work where there are people in waiting rooms right now in the primary care offices that probably could have had their issues solved by a phone call or telemedicine visit by changing payment models to lock in those revenues for physicians we can do that more often and eliminate administrative burden in the frenzy pace of the ten minute physician experience that you go through when you visit your primary care doc certainly as we take risks asking payers to eliminate the things that they put in place strictly to try to do something to mitigate cost growth in a primary care service system like prior authorizations, I think we can make a big difference on that. Certainly I'm trying to work with our CPR practices where we lock in a once monthly healthy capitated payment for their attributed lives, have them think about process redesign and do something that's different from that payment model because right now I heard Dr. Raven talk about work at the end of the day, I mean North Ward who's a primary care doc and still seeing patients work with me every day and I see him do that at the end of the day and we talk about the fact there's a couple hours that he does now to respond to some emails about the patients or he doesn't pay anything for that at least in the models that we're implementing to lock in the revenue and allow primary care to think about re-optimizing their processes and how they want to do a layered payment management process and know that the financial resources are there to pay for their space pay their salary and pay for their nurses and practice support personnel okay apart from 25 million investments in programs that is directed to a primary care is about 14 million, we are paying a supplementary PNPM for any attributed life that's above and beyond the blueprint for health payments including our replacement payments for Medicare we're paying $15 for a member per month for every high complexity patient that they attribute based on risk scoring models we are offering additional PNPM if the primary care office decides to be the lead care coordinator and make good use of care now here to do that to both communicate with the patient and with the continual care we've made primary care the majority recipient of our quality incentive funds these are quality incentive funds that are measured as a percent of our own target that we set aside one care to pay back up to providers based on quality and that's hospital money we are keeping and giving 70% of a back to primary care if a hospital avoids primary care they'll get a piece of it but a bunch of this is part of that redirection of a slice of the pie from acute care to primary care of all types preserving the Medicare blueprint funds for the practice payments to CHT we've covered that a couple of times just to show you that there's real money here in terms of that hierarchy of support in our standard model this is called our standard model the CPR is our innovative and future model but you can see 2.6 million dollars at the top of their own note to the patient center medical home for our complex patients we are getting some money out to those designated agencies, home health agencies and area agencies on aging to try to extend to a more coordinated system and to try to get a system where some of those community based organizations can make really really good use of being our arms and legs and ears and eyes with those patient touches out there that they're already making a huge initiative for a lot of our tribute patients so we're really trying to what payment models are bringing them to tie in with the medical home model we probably haven't got the secret sauce completely figured out on how to really make that in and you know can get the tool sets really coming so it doesn't seem any more burdensome than it has to do with that coordination yeah that's a journey that we're on okay I'm going to turn it over to my colleagues then we're going to take it through to the panelists to patients and the providers when I was here last time I heard some sort of question and concern about how we are working to as we're building the airplane that Todd described earlier how we are bringing out all everybody along for the ride as you know it's a voluntary network with our providers and as we've been building and working to implement this model we've been working hard to think about the best ways to make sure that we've got transparency and open and honest communication with our network and so the next slide here was and I won't go through this line by line but we just wanted to sort of try to quantify for you a little bit that even just in this first part of the year we've been trying to reach as many providers in our network as possible and through the fastest and highest impact for that has been through our WebEx series where we've been starting early and doing a major overview of everything we know up to date but then as we progress and the questions get more specific we've zeroed in on some topics that they express interest in hearing more from us about you know for example financial revenue cycle and operations we've done separate ones on quality measures and just trying to give these opportunities where providers can ask questions in real time and also make connections with sort of the one care teams that they have a feedback mechanism that if a question comes up that they need an answer to they already have made a connection with somebody there that they can pick up the phone or email call and they know right where to go to get those questions answered and we have been collecting those kind of one off questions that come in and figuring out ways that we can then share that with the rest of the network because if one person has it we suspect other people do so we are in an ongoing process of establishing regular output to our providers to get questions answered provide information and just keep them as up to date as possible and bring them along for the ride. On top of that we have the leadership team at one care has been making in person visits to our risk bearing hospitals and we've been focusing somewhat on our new entrance and these are sort of half day to full day sessions where we really really deep dive into any sort of questions or concerns they may have. We give them any updates on what's going on with us and what we see as our path forward in the next few months and really establishing these great relationships that we all feel that we're part of this and we know what's happening and you can sort of see some of the sites that we've hit so far. Our chief medical officer has also been to Springfield and to Dartmouth but we have another coming to Springfield and we'll keep going with the rest of the communities and finding ways to interact with them as well. In addition to that we have, as Todd mentioned earlier, we've been traipsing the state and training over 200 people on care coordination skills trying to give them some of the tools that they may want or need to help implement some of our programs. We've trained over 600 people in Care Navigator and Workbench 1 in our software to help them feel comfortable with using it and also have an opportunity to ask questions, raise concerns and be part of the process as we develop this software and get their information and feedback as we go along. We've done multiple trainings throughout the state on quality measures and population health management care coordination and existing and new communities. We also have clinical consultants that we've hired and paid to be in each health service area to help be a liaison with our community care partners and with our partnerships there to help just sort of create some additional support in the area and establish bridges from what's happening within the communities to one care as well. We've recently been developing and updating some FAQs and provider resource documents that we're making sure to email out to our network and give them any information we can in sort of written form that they can file away for reference documents and also give us feedback on if there are things that we're not addressing that they might want to hear more about. And all of this again is just a larger effort to create a feedback loop so that providers that may have questions and concerns feel like they have an opportunity to address them directly with us and to establish good working partnerships together. Another piece of what we're doing that benefits our providers is this quality improvement clinical education and training and one of the hallmarks of this effort are our brand reference topic areas and as it mentions up here we do four sessions a year. We don't actually restrict these sessions to one care the one care network. Any and all interested parties are allowed to come in person or participate by WebEx and we've had you know on this side you'll see some of the our more recent topic areas just this past month in March we did dementia care in Vermont which was one of our best attended and it was available for the providers who needed CUNCME credits they could participate and also get some educational credit for that as well and we also keep all of the materials available so that if you weren't able to participate they can go back in and get these enduring materials and still receive their credit for it after the fact and Todd mentioned our learning collaborative topic areas earlier these are really great collaboratives that we work really closely with the blueprint on to engage on these 10 month programs where providers can work together to figure out strategies and as I mentioned diabetes is the topic of this year and that program has just been kicked off and there's been a great amount of interest from providers to be part of that and to dive in and help improve quality and care for their patients and the last one I wanted to mention is we have an annual symposia where the topic for this year is COPD and another educational opportunity where they can receive credit and just learn from other practices of what they're doing and share and have a great educational experience and join with the network. Turn it over to Joan. Okay, so we have a small customer service department at OneCare that holds many functions one of them is to support our patient questions and provider questions focusing first of all on the providers. The primary reason that we get a call through our general customer service line is questions related to something that's different about our risk programs and the big difference for our hospitals and our CPR folks is really the receiving of statements and a different financial model so they may be asking for access to our portal or secure portal that is on our website and we can reset the password and get them in there and show them where their documents are stored relating to their latest financial statements and also their attribution lists. We post up the attribution list that we get at the beginning of the year by each of the payers and then any of the changes in attribution as the months go on so that they can tie their patient panels to what they're getting paid. As far as tracking and monitoring we have a process of every call that comes in is tracked through a very basic SharePoint system and we have already last year through our Vermont Medicaid next generation program. We had to create a very regimented system for providing reports monthly on the Medicaid program that was part of our readiness that we went through for the Medicaid program so we have been bolstering that work that we did for our Medicaid we've been working with our two other payers, Medicare and Blue Cross and we're really leveraging those same kinds of reports and the same ways that we're handling the increase so that we can have a little bit of standardization in the patient experience or the provider experience as well. In terms of reporting we do provide reports to Diva every month and we have had conversations with Blue Cross they like those reports they're comfortable with receiving those and those will be provided to them as well as to our Medicare contact on a monthly basis also from the Medicaid board there's report requirements on that side as well. In terms of any escalations for providers we have a lot of collaboration to provide a community over the years that we've become an ACO and so we do have a lot of different feedback loops in order for our providers to provide any negative experience that they might have it might be the clinical consultant that's in their health service area it might be one of us who go visit those communities. There's a lot of different forms for feedback and we take that feedback seriously however if they did have an issue with us that we could readily resolve then we do have an escalation process and we do have grievances and appeals process for providers. So as far as providers go we have a very concrete appeals process whereby for the providers especially if you think about those hospitals that are getting used to fixed payments it's really important that they have an escalation if they're uncomfortable with how they're being paid again our hope is to collaborate with them and we certainly spend a lot of time going through modeling data and information to help them feel comfortable that things are ticked and tied and that there is reconciliation across the entire process but that's where maybe a tangible example of where I could see that someone could be uncomfortable and potentially request an appeal we haven't had a grievance or appeal from the provider community to date and I don't necessarily think that's a negative I see that as being an outcome of all of the hard work that's been invested in creating provider relationships and being transparent about how we have created these models with their input through the various committees and groups that we formed as well as one on one but we certainly have a process should that occur and we will be sharing that with through all of our various payers and bring back care boards should that occur in terms of the provider increase we've been tracking those since the beginning of our Medicaid program and where we have seen the increases are around the sort of beginning of each new year when we have new communities coming on board and they're getting adjusted to the different type of programs that we are that they're in so typically the questions that come to us as I stated before are around really just getting acclimated with the payment operations and getting into our board before the attribution data that we need to receive so as you can see the number of increase has been fairly low and that is probably that looks like that will continue as we continue to engage with our network in various forums to manage the need so that we can be more proactive and they don't have to then come to us to receive information as far as the patient experience goes I think I really like this chart because for me it reinforces how important the patient is for us in the ACO model that's why we're here that's what we're doing and the provider communities is surrounding that patient that's why we have systems like your navigator that we really want to embrace to focus on the patient and the patient experience surrounding the patient they have many different options for support they still have a direct relationship with each pair so Medicare, Medicaid and Blue Cross they're not going anywhere they're still processing claims they're still supporting the patients in terms of their benefits we haven't done anything different with their benefits that relationship is still a one-to-one so we hope that as an ACO we are an additional part of this healthcare system that provides additional support to the patient that will help them and we will work with those other pairs should they need there to be a more integrated solution to one of their questions this slide is an overview of the one time that we have a real direct relationship with patients in terms of the more business side is really through our notification letter so we are required by each program to send out a notification to our patients and I believe that was also part of the being that careful of requirements that we notify patients if they are part of an ACO and we have we started out last year with Medicaid so we have a letter that we wrote with them that we think is speaking to the patient at the right level in the right way and we're very comfortable with that letter we sent that out this year and it does give them in that communication the ability to opt out of data sharing for claims data sharing so that was already sent out and then we then later sent out the Medicare next generation letter and that one was we were told by Medicare on what we had to send out we were not able to make any revisions to the wording of the letter it did create a lot of confusion so we have been in touch with our Medicare representative to give them input on the patient experience because we did get some calls from patients who were just really confused by the way that it was worded and our representative from Medicare is very open to receiving that input taking that feedback and working with us next year to write something that is easier to understand for Blue Cross we have worked with Blue Cross to share the current letters that we have for the Medicaid and Medicare versions and create a version that we think again will be least confusing and most educational for any patients that are newly attributed so we have a letter that we feel is very well worded and that's going to be going out at the end of this month with that letter we are also going to include a frequently asked questions document again that was something where we heard from Medicare patients live and clear and from providers that we really need to explain our ACL model better so that we are providing education that makes sense from the patient experience the table at the bottom really just shows our optite rates from last year it's low on the Medicaid side at 1.6 at Medicare it's 5.3 and last year for the short savings program there were no optites we will share the optite rates for this year as we finish that process of sending out the letters and receiving any responses from the patients so in terms of the customer service for patients again we have a staff that answers any questions that come in they are really initiated by patients once they receive the notification letter that's when they really get an idea of being in the ACL and there has been of course some more press coverage about the all care model and so some patients are interested in what does that mean for them so a lot of the tone of our calls is really about educating the patients on what an ACL is mostly it's about reestablishing that we're not doing anything with their benefits and that they should continue to go to their same providers no matter whether they're in or out of our one care network their providers are still delivering the same care and that they are able to call their pair directly with any of those benefit related questions in terms of reporting again we're following the same process with both patients and providers in terms of the work that we did in readiness for the Medicaid to next generation program is being elaborated to the three pairs and so we are able to provide that one forward on the patient side we have not had any formal grievances to date we have offered that option we have worked with the healthcare advocate to make sure that we have language on our notification when you're allowed to make that change and we certainly have it in the Medicaid and the Blue Cross letter to say that they have the option to call the healthcare advocate and we are asking any patients when they're on the phone if we can't readily resolve would you like to file a formal grievance that's part of our scripting that's part of what we do and that today we just haven't had an occasion where someone has not had their question resolved in terms of the number of patient inquiries they're certainly higher than our provider inquiries again because of the notification letter and because of the recent press coverage about the all-time model so we are managing those emails and calls and responding to them in accordance with our policy we just wanted to sort of you Joan mentioned with the beginning of representation and I think that show that we really do have the patient at the center of this and we take our patient and family centered approach very seriously we have as Todd mentioned earlier a patient and family advisory committee this group reports directly to our board and it has patients it has families of patients it has some of our providers and board members on the group that they work really hard to solicit feedback on how we're doing and what we could be doing better and we take the advice of this group very seriously our patient and family advisory committee is also working to with the UVM Medical Center has a large patient and family advisory committee so we've been seeking some advice from them and some feedback about how we could be doing some of our work better to make sure that we really are keeping a patient and family focus in our work and then finally all of one care staff has received training on this approach and we have an internal working group within our office that is working to make sure that we are feeding this approach into all of the different initiatives that we implement information to the public so we've been working hard to sort of get this program up and running and to make sure that our providers know what's going on so we are now also trying to fold in some efforts to engage the public on the work that's going on here with the all-pair model and the ACO and we've recently been updating our FAQs and putting together information packets and working on disseminating those we've put some up on our website we've gone to some events recently where we've been providing packets of information and just trying to get a little bit more information out there and then also hear back from people about what other questions exist that we're not addressing for them and trying to continually adjust our materials and make sure that we are meeting the needs of the public and interested parties and some of that has been that we are soliciting some help on this we've been bringing in some advisers and some focus groups and just sort of asking whenever we can about what we can be doing better and what we should be adding and that's been really useful in helping us figure out our different audiences and the information that each group is interested in hearing about so we'll continually evolve those materials and as Joan mentioned we've received permission to include the patient FAQs in the notification letters that are going out to give them when they're getting this letter a little bit more in detail about what we're doing and we've also provided them to providers and not to place the educational burden of the ACO on providers but giving them some materials that should they want it and should they need it they do have them available to help answer some sort of initial questions and we'll continue to work with our provider community on how to best do that. We also engage really regularly with sort of stakeholder groups that are interested in the work that we're doing and constantly soliciting feedback and making ourselves available to attend meetings and provide information and updates whenever asked to and whenever we have something that we think that we want to share with them. You may have visited our website recently and we acknowledge here that it needs some work and we're working on a pretty significant overhaul and making sure that we're addressing questions of the public better and making sure that we're addressing everybody with different payer methods instead of just focusing on the original intent of the website which was for Medicaid. So this is a bit of a process as we have to get CMS approval on some of the information that we post on there but we are actively working to make it a more user friendly experience and provide more detailed information. We also are trying to expand our region we're recently invited to attend a community forum in Bennington and we've been using some of the feedback that we've been hearing from that forum to help us change some of our materials and figure out how to best approach the public and to meet the needs of each audience that we're addressing and there are many more community forums that we want to do and we're working with different communities to figure out the best way to offer that up for the public as well. The event in Bennington was very interesting. Dr. Ward and I went down and did that and it was scheduled for an hour and a half with two hours and 15 minutes. They had about 40 people from the community that showed up and stayed almost all but maybe five stayed the entire time and it ranged the gamut of those 40 people to I'm sorry this is about healthcare. Can you explain why you would get invited to this all the way to how you set for your primary care so that's one of the things that we're trying to get our arms around is the more that all care modelists is known and people have questions they're going to be from the most basic two very advanced questions and we just got to get good at that because we do want to be responsive and get that information out there. Okay, it's part of the wrap up challenges. Part of that. You said previous slides and challenges and brief. Please focus on the brief because I really want to give the advisory committee time to ask you questions. Okay, challenges. Not on the money to do everything you want to do. Moving money around is a hard thing. Trying to get the calculations right is hard. Working with three different big payers with their own challenges. Dad, the data lacks it's really hard to work with and we've got the best out of people in Vermont working on it but it's still always just elusive. I'm really having a problem as soon as we want to. Operations including notifications to the patients. I think just, you know, Jim overseeing a team if that's what they do, you know, there is a real operational challenges to live in these models and to try to do these processes well. So, you know, typical set of challenges that you would expect that we feel. You know, coming next is how we do it in 2018, how we work across the risk threshold in three big programs that's going to be really, how this year goes is going to be really talented and we're, you know, on the cusp of having our first early data. Self-insured, I mean, one of the things that we need to scale targets in our hair model is how do we bring in employer sponsored health plans into the mix and we've got to probably, as an ACO figure, how to put a stake in the ground to offer them predictability and affordability for what they spend on their benefits for their patients in a real way to show them that there are benefits from this overall 3.5% growth rate. And then finally, you know, we're in full cycle of our budgets for next year that has to start with who's in the network because that's the basis for attribution that everything else comes from. And so, Joe's team of operations has sent out solicitations out of what you're planning next year to attend the state one here if you're not ready. If you're in for one program, do you want to go to all three programs? Do you want to join one here next year? You do expect additional network participants to join on next year. You know, I think a lot of folks wanted to see how this really worked and they liked a lot of what they heard. And it's a little bit more tangible now that we've gone through the process of figuring out how this all-hair model really works in the EU. Get briefing up. That was great. So with this point, I'll open it up to questions. Yes? I think we're missing opportunities in keeping people out of this health care system and chronic disease we all know is the big player here. In primary care visits, we'll test and they will treat symptoms, but you addressed it just briefly how we can reverse the chronic disease. Actually, even before a symptom is on the map. We know if somebody has a history of that and their family and their gaining weight, that is already an indicator that they're on course. So the point is not to wait until symptoms come, but to actually reverse things before they even show up. But I don't hear in this system effective ways of doing that. I hear a lot about just the re-management of sick care. But if we really want to decrease costs, health care really is our focus and not sick care. We need to invest in programs that have outcomes of showing this success of reversing disease with exercise, nutrition, mental health. And that's what I want to hear more of. And you know we've been trying to get on board and I have not had a discussion with one care yet. No one care person has even looked into what it is that we do in the management of chronic disease. And we want to collaborate with the hospital and primary care providers in helping them. If they're overburdened with visits, wouldn't it make sense for businesses that work in health care management to take that burden off of them by giving them alternatives? But we need to have somebody serious look into it, and we need to understand that it will take funding. And I don't hear any of that here. Yeah I think you did talk with the emergency meeting and you had a conversation with her so I can't talk to somebody. Other than that, I agree 110% of what you said. But among the challenges is we don't have unlimited time and bandwidth and we've got to pick at least in these early first couple of years what do we think the things that truly have the best chance to prevent really hospitalizations. So we're looking for where's the shortest return on investment to get this to pay for itself that crime into pump money. And unfortunately that's probably in chronic disease management and managing those who have a track record of being in the hospital multiple times per year are complex care coordination. So it isn't a philosophical disconnect. It's a time bandwidth trying to look for where the real return on investment is in the early years. Now, you know, my Rice Vermont story is again a quadrant, what we call a quadrant one strategy because we risk stratify our treated population into one, two, three and four for being the most complex and sick and one being largely well in the absolute chronic disease. But that's where also the quadrant where there's, you know, pre chronic diseases, but also things that could be, you know, a slippery slope long term of people becoming less active because they do have joint pain that could be helpful physical therapy or other things like that. So we're not against any of that. It's just a matter of trying to figure out which programs and engagements that we can take on an annual basis that we can execute well. I don't want to do a program unless we have the bandwidth to actually get it done. We have time, money, attention, etc. I just want to follow, because I don't think you understand physical therapy and we have people bringing their elderly parents, for instance because they want to stay at home and live independently. And insurance doesn't cover this, but the number one reason why an elderly person ends up in the hospital is they fall. This is great. And everybody's at risk for falling, but nobody's really working on that. But a business like my own takes these people in and they work under membership and they improve and we have a way to measure their fall risk. So this is what I'm talking about. I'm not talking about physical therapy and rehab medicine. What I'm talking about is preventative care and direct care, not of symptoms, but of the problem. So part of our community-based organization in the process with carry agencies on aging who probably touch seniors more than all of us combined, oddly enough. But home health and designated agencies too is to address some of those things. I don't know whether your organization does have that many touches that maybe we do need to have a dialogue, but to address your exact issue is how can we work better with home health when they're in the home and already physically there and making a visit on some medical issues to look for fall risk and other things. I don't know, Jill, do you want to comment on that in your agency nurses visit? The area agency on aging trying to figure out how to make use of the fact that they deliver meals on meals in other programs that touch the seniors. We do care about those things and we're trying to implement programs that do just what you're talking about. Yeah, that's where I'd be curious as to what you folks think about accountable health communities and how you see that concept in your future. I don't even know what you know about accountable health communities. But when I listen to these questions and these conversations, many of the short answers to these questions is yes, there is a way. An accountable health community would apply beautifully to what that person just described in terms of, I guess a question or a first person or a dilemma. Because in accountable health communities, you have these various agencies operating as a team. So you have the counseling agent, you have home health, you have the mental health people, you have them all in the room working on this stuff. And when I listen to these things, there are simpler answers to these problems that I think... Paul, I don't think this is hard. Exactly what you're saying is exactly what is happening right now in communities that are located by the E-printed one here. So I'm just not sure what the distinction is. I think that they're one and the same. I'm not sure because there are different levels of functionality across the community. I'm thinking about what I'm used to. I don't know what you're used to in your communities. I'm used to getting there and getting these organizations together to discuss the issues you think about. I'm simply presenting a concept that I think could answer that. It's nothing that has to wait. That's all. I don't even know how to... This is an advisory board. I'm not even sure how we give advice. You can give advice at any time while either verbally or written. I'm sort of piggybacking on what was already said in the way. Being that the Medicaid Pathways project all but vanished with the SIM grant, do you see any compensation in the APM-ACO model like long-term care services and so forth? We owe, under all of your model, a plan in year 3 which is 18 months from now. A plan for how we would do that, bring the payment reform and accountability for spend on a unified basis that brings in some of the additional spending on long-term supports and services that aren't currently part of the ACO budget. It's within the life of the all-care model that we would explore how that would work. In the meantime, we have community-based organizations on boards, committees, governance, local continuum of care discussions and engaging them because they help us do well on the part that we are accountable for now. I would want to really encourage, and I've done this a lot through Vermont Care Partners, especially and through Vahapajil's Association to really talk about getting those agencies ready that are really sort of a bunch of independent agencies, but with a lot of common interests and desire to be part of popular self-management in a real way to continue to align their information systems, their approaches, their capabilities, and I sometimes encourage them to form, and I mean it's literally a community-based services organization to be a companion for the ACO to drive more commonality. It's easier for me to support a program statewide if all the agencies that might be the arms and legs of that program are ready to sign on and move ahead and that's really what we're trying to do is try to put more consistency just like we are in ACO, but in programs that we can measure the return on investment and implement that will touch enough patients to make a difference. Jill, if you want to. Yeah, who calls on me? It's not me. It's not you? Okay. Jill Olson. Okay, thank you. Jill Olson, I work for the days of Vermont, so we're the home health agencies. Vermont's not for profit home health agencies. And I wanted to comment on a couple of things because what I'm hearing this room grapple with is so similar to what I'm hearing in my boardroom where we talk to all of our members. And I think that's what is the role in our communities to do all of this work. I think we have a lot of shared goals versus what is the role of the ACO and what do we need for them to get the work done. Home health agencies are really incredibly engaged in this work. There is not a single home health agency that has not come into one care once their hospital is in. So if the hospital is in, the home health agency is in. That's true across Vermont. I think we are the only non-hospital group that has that level of participation. And so my members I think have just sort of taken out, well let's just jump in and do it approach. That's kind of how they work. They're in the SASH program. They provide all the nursing for SASH. They do choices for care and long-term care services at home. It's just kind of their culture. But I think we are really trying to figure out what we do in our communities and with our hospitals and with those existing relationships versus how can the ACO support that work and make it happen. I think it's going to be a long time before we have those answers. To me, when I hear this presentation, I hear three big things. One, hospitals are now in risk-based contracts. I used to work for hospitals 10 years ago. I would have said that will never happen in Vermont ever. So it's now happening. I think that there's an acknowledgement now that the community providers need resources invested in them. That's through those PMPM payments. Is care and navigator working the way we would like it to? No. Can it replace people talking to each other? Definitely not. But the acknowledgement that we need to move some resources out of hospitals and into home and community-based services? It's huge. It's a total game-changer. There's a lot more to do, but there's finally some progress. And then I hear a lot of experimentation. I think there's a lot more of that to do and I don't think we're going to know the answers again for quite a while. That's my soapbox. That's what I've been thinking about for 45 minutes. I don't think there's a question there. I just have a technical question. So you're getting paid a lump sum for care. Where do people's out-of-pocket money fall into this? Do you want to sell any basic co-pay? That's a great question. In these programs as it exists now, we can't affect the benefits, so there's still full card-carrying members of Medicare, Medicaid, and lacrosse. So the technical answer is we can have any of our contractor providers, we can choose to get a pre-payment to the lieu of fee for service. And we do that primarily for the hospitals and those three doctor and care practices in the CPR hiding. Everybody else gets paid fee for service from a payer. But even for the care encounters that are part of my fixed payment stream, the payer adjudicates that like it was a fee for service world and calculates the patient payment as if the system was still fee for service. So just there deductible, somebody goes to the hospital and they've got $5,000 to pay. Does the hospital get the $5,000 or does Blue Cross and Blue Shield hold on to it and pay you that one lump? The provider is still collecting out of pocket as they otherwise would, in addition to getting their monthly fixed payments. Okay now, obviously what we're trying to do is deliver the same care in a lower cost setting and be sure that we couldn't do anything to prevent an emergency visit or there could be a $250 co-pay that could reduce patients out of pocket. We do a good job doing what we're talking about, keeping them out of the hospital, which are the deductible busting encounters. Yeah, we can't swing it too far though that we're not going to care that they need or making sure they have access to the emergency room. But their benefits still apply. They can still use any provider at any time according to their benefits. We don't have any tools in the toolbox really to prevent it other than just in case you're their primary care doctor and with the patient, and across the team of care to coordinate around planning and anticipating any improvement. Curious in your CPR practice is about the ratio of patient panel to an FTE provider and whether you have a goal in mind as you look forward or as an ideal number or just what thoughts you have on that. Yeah, and I think this is, you know, every journey we've been through with a single staff we've been providing what we think is a much more adequate revenue stream on a panel measured basis and prepay that. Now the question is in these practices, now that we're sort of operational with a model is, okay, how are you going to think about the world differently? And, you know, some of the practices say, I wonder if I should use the extra money to hire another physician. And others might say, well actually we're going to invest it in a couple of care coordinators to help reduce the opposites of the physician can spend more time with the patients. You know, and others are just, this is paying us back for the 10 years of being asked to do more and we think that we're in full compliance with what you're asking us to do so we're okay. And we're not going to answer for every practice, but you know, I think that we'll delve carefully into the world of looking at is there an optimal process design? Is there an optimal team-based structure and workforce development plan? And is there an optimal panel size for a practice on either per-clinical FT or doctor basis? You know, we're really trying to circle around that because every practice is so different in terms of their panel makeup and the way they constructed it that we're really just early in studying, you know, are there some best practices we can offer? Because I think we get stuck in the, like I said honestly, these practices trying to live through the day. When they're trying to live through the day and now they're an ACO, there are some extra requirements that we think can help them deliver better care to their panel and on top of that, oh by the way, I'm going to spend a couple hours working on process redesign and thinking about your, you know, team-based structure. That's where it gets a little tough and we need to do our best to support them because they're, you know, having their own version of building the airplane wallets and everything. Back to Ryze and ET. Were there outcomes from the Northwest pilot that spurred the statewide expansion? Yeah, and it's probably worth you trying to find somewhere in the publicly available video or documents their presentation that we found so compelling at OneCare and our board found so compelling that talks about what their successes are. Also embedded in that program is an approach to reversing, and I mean reversing, childhood obesity rates on a population basis using a methodology that has 25 years in some countries in Europe, 25 years where the evidence that it works and the St. Alvin's, Ryze, Vermont program's going to be the first internationally recognized, what's called the EPO that's an acronym for, in French, let's together to prevent childhood obesity. We're the first ones in the United States, there's a lot in Canada, and about many European experiments including entire countries that have applied this approach, so we, you know, I know that they've had great success in St. Alvin's measure and are pursuing a model that does have an evidence-based impact on childhood obesity rates that we've had. One of the challenges in population health and it's sort of the disconnect between what people pay for deductibles and co-pays and what gets paid is working with employers communities. I'm with the Vermont League of Cities and Towns and we used to have wellness programs for employees, but when Vermont Health Connect came in, that sort of fell apart. I worked on a planning commission, you know, we'd make city plans, we tried to consider public health as a factor in a city plan so it spreads all over, but my concern is that we don't think about employers, we don't think about making compelling arguments, for example, why shouldn't employer be interested in this stuff because if you're in Vermont Health Connect plan you can do all the great things in the world to have a healthy workforce, but it doesn't change your rate compared to anybody else. There's no reward for doing it in terms of health costs but there are a lot of other rewards that come from having employees who are healthy and engaged and to the employer, and I don't think we do enough to talk about the community benefits of things beyond just the long-term cost piece of the factor, so I'm hoping that's something maybe you can consider helping put out out there. All great points that I agree with and you know me personally at the time of my attention this year to the planning of exactly that is how do you bring in employers in a way that offers value to them and makes it possible for them to want to partner and be a part of the ACO based model with their character. One last question. I hope this wraps it up. There's a difference between you had a bullet about patient and family centered. And the difference between patient and family centered and patient family directed, particularly home and community based models, so do you have any do you have an outline of plans for patient and family directed care as I said, particularly in the home and community based aspect of it? So we talk a lot about shared decision making trying to use the relations they have with caregivers and physicians within the network and creating that dialogue. You're trying to be more proactive to reach out to patients to offer dialogue in terms of how can they better engage in their own health. That will continue. I would say we're barely even nationally scratching the surface for how do we get smarter around how do we get people engaged in their own health more. Part of it is lowering any barriers that they have bigger things to worry about in their life to engage in their own health. How do we motivate and interact with some people? I would suppose that there's some people that probably respond well to text based messages from their doctor's office. Others, you're really not going to get their attention until they're sitting and examining with their doctor and the doctor saying, you really got to change your behavior. I would love to work on at some point in this five year period how can we get smarter around spurring patients to take more control of their own health. I will tell you in a lot of forums the things that doctors really, more often than anything else, want to tell me after administrative burden is, but I've done everything I can to try to get patients to change their behavior. If you're going to hold me accountable as a system for the outcomes, I know the only way we're really, really going to do well is to change some of those behaviors. How can this work, this accountable health system, if a big part of accountability is then? So I would love to get some real thought about that during this five years and be a leader in Vermont on that. Another area of opportunity that, again, I just don't think we've really figured out the right way. So thank you team one, Kara. It was a very, very good presentation. Did the advisory committee find this helpful? This type of versus what we've been using in the past? Well, I saw this one a little first. Go ahead. I think it's always interesting and a learning experience to hear the detail. You're getting about it and I'm going to have a presentation. At some point it would be very interesting to me to spend some time with alternative ideas. There are, you know, I took all kinds of notes on things that I think would be helpful to advise you and you to advise us. We're hearing one world in life, there are many others that I've heard here today. I think we're all interested in improving the health of Vermonters. Firstly, I'd like to share a little bit about some of the scourges in our design. The Scourge of Mental Health Challenge, the Scourge of Substance Use Disorders. I've heard some things that are very helpful today, so this was good. I would like to hear more about a comfortable health community and I know you folks are coming to our part of the North. We'll be there next week and this is very helpful for me to shape some of our thinking that we'll be able to present to you. I was actually hopeful, Paul, that we could target the next advisory meeting next quarter on Mental Health and I wanted to ask the advisory group if that is a topic that they would be interested in targeting that meeting towards. If Paul mentioned it's one that he would like to learn more about. How about others? I'll also add that we will be sending a survey after this meeting and some summary notes so that those didn't have a chance to comment today. It would be great to have some of these comments in writing so we can read them. I know that some people now get a chance to ask some questions. They could even send those questions and we could seek the answers. So yes, go ahead. I would prefer actually having more presentation presented to us like a link on the internet. And then have more time engaged in discussion. Questions and discussion. I heard that the people presented would like to have that as well. So I felt too much time was in the presentation that I could have gotten on my own and had more interaction. Had minds be thinking as they're listening to these opportunities. So I think it's like equal time for presentation and equal time for questions. Yeah. More time for discussion. Not just questions but let's take it a step further. Exactly. Explore. Does anybody think that it would not be a useful use of our time at the next quarterly advisory meeting to focus on mental health? So I guess that's what we will do next time Susan. I'll also add that our next meeting is August 1st Great. So again I want to thank Team 1 here. And also we know Melissa from our staff that was a very productive morning and I think everybody wishes we had more time but we're already 10 minutes over. So at this point the board will be in recess. We're going to start again at 1. And thank all the members of the advisory committee for this morning. Thank you. Thank you. We're excited to demonstrate the surgery center's compliance with the first seven conditions of our CON conditions, the eight conditions which we need to demonstrate compliance with before beginning construction on the facility. We are planning to start constructing the facility by the end of April. So with a couple of weeks lead time here now I wanted to come and demonstrate our compliance. So if it makes sense to the board I plan to just go through the first seven conditions one by one and can take questions as they come up if you haven't. I also should say that I do have with me Jane Evans here today who worked on developing the website. She will be taking notes of any feedback or suggestions and that there's questions that I can answer that you have. I may ask for her if that's okay. Alright. The first condition is the development of a consumer friendly website which shall provide information about each position planning to offer procedures and surgeries at the surgery center. So we have developed a website on a development server right now and what I've done is taken screenshots that are relevant to each of the conditions of that website that's on the development server. If you were to go to Green Mountain Surgery dot com right now you would see a really place holder site with some pictures in contact but not a lot of this information which is on the development server which is not yet public but will be made public once we populate it with the accurate positions information. So this is the home page. The menu bar at the top is meant to call out the key items that we wanted to make easily available for patients and consumers who intended to visit the website. Physicians has information on our positions. The team is the staff of the surgery center. The tour will have pictures and we have the quality information, the prices of the procedures and the resources there at the top as well. So getting into the meet behind what was required in the website in condition one the physicians name, professional credentials areas of specialization procedures etc. We are going to display all that in the position profiles. So we are going to go into one of those as an example right now, Dr. Carlota, Alan and Dee. These are not real positions right now. These are place holders. These are models obviously. I have had some physicians say that they don't think they'll be able to operate the center because they're not good looking enough. But I'm sure that's not a criteria. So when you click on one of the documents you can see here, this is the physician profile page and this has a lot of the relevant information that we're looking for. First a little bio on the physician, their philosophy and their amount of experience. Right up here on the front in the last sentence is where we intend to call out whether the physician is an owner of the surgery center or not an owner of the surgery center. So you can see there that's the last sentence of the paragraph Dr. Alan is a minority owner of the Green Mountain Surgery Center. The button on this page is to the physician's website which will be their normal practice website which has the information for their office, their office hours, the other physicians in one group all of that. So that's where you see that physician website button located. So this is the top of the physician profile page I'll move next to the bottom of the page where we have more details when you're actually on the website the whole page will show top and bottom but I had to split it up for in the interest of putting in on the slides. So at the bottom just below what we saw on the previous slide is in a box with three tabs where we'll call out the physician's credentials and here we're showing the credential tab then you can click through to see where they have hospital privileges and then the third tab is their procedures and surgeries this is shown in the credentials where you intend to display that information. The physician's 24% of the contact information for patients will appear there on the bottom of all of the tabs and the position profile page so that it will always be shown. The hospital privileges will just call out where the physician maintains hospital privileges at hospitals in Vermont and the final tab will have the procedures and surgeries that they do. In that yellow box we plan to show a list of the five most commonly performed procedures for this physician and we will also put information there, the admin's basis for recommending surgery and how the procedure and surgery improves health this is to comply with one the fact condition there then to obtain information regarding the procedure and surgery history by parents at the center and other local hospitals that is a pretty dense amount of information so we have elected to put that in pdf form rather than show all that on the website page there's this button here that you will be able to click which will open a pdf of this information and this is to comply with condition 21 which calls for a number of things the procedures and surgeries performed at the Green Mountain Surgery Center so we'll have the code, the CTT code of the procedure that they perform, we'll have the name of the procedure colonoscopy, scan lesion removal etc and then we'll have the total number that they performed and we'll then update this information quarterly and we will have the number, probably the annual number although we break it up quarterly and put the annual number there as well but for patients the annual number of surgeries I believe will be most relevant though we can update it quarterly and then we have procedures and surgeries by the payor mix on here, commercial medicare, medicaid care procedures, then we'll have procedures that number performed at local hospitals, the names of the hospitals and the payor mix at the hospitals as well which is asked for your condition 21 as well the total number of patients who are inappropriate for care at the surgery center and their reasons for those determinations will be on this spreadsheet and that covers the requirements in condition 21 the next part of the website that's relevant to show is the quality measures these currently are the 12 medicare quality measures that are required at all surgery centers report on for medicare, we plan to show our score and that comparison to the national average on this page here continuing on the quality page is where we will show the surgery center's revenue by payor category quarterly for the last four quarters those are listed as quarter one, quarter two, quarter three, quarter four now, we'll of course put in the actual ratio that refers to once we're up and running that will also show the volume of procedures by payor category these three charts, these two and the one on the last slide will comprise the quality page of the website, the next page is prices, again I've been in that top many quality bar this is how we intend to show the prices for our top 25 procedures listed here the name of the procedure Tico the procedure name and description the self-pay price, the commercial price which not having had detailed conversations with any payors yet we're going to have to work out the most appropriate way to show the commercial prices we are betting right now that we will try to show a range and not have identical contracts with each payor so we need to show the range of commercial prices there without like identifying individual payors but as I said we're going to try and aim for an arrangement on the commercial price and then the Medicare price will also be listed for conditions A2 and A3 which both relate to two of our key policies that must be on the website one is the shared decision making policy and one is the payment status non-discrimination policy those are the five or two policies of this list the way consumers will access these policies is on the footer of the website which you see there where it says address physicians policies and resources the policies are there when you click the view all button you will come up to this page the footer appears on every page of the website the home page and every other page so this information will always be accessible no matter where a consumer is on the website when you click on one of these bus boxes the entire policy for the edge is displayed there so that patients can review it before deciding to visit the center this is our non-discrimination policy you also have a copy of that that I submitted as part of the packet that was prepared for us and reviewed and approved by the Greenmont Servers and Board of Managers on March 13th and posted to this development website March 13th as well the policy that relates to condition A3 is the shared decision making policy which is shown here you can see the whole text here in the slide you will see the whole text on the website page and you also again have a copy of that policy in your packet this was developed based on materials regarding this patient decisions aids and shared decision making that have been prepared by the state previously in 2009 or 2010 when this issue first started to be investigated in more depth and the state worked on a report on shared decision making communication aids and we leveraged that a lot to shape this policy which again has been reviewed and approved by the Servers and Board of Managers on March 13th and uploaded to the development website so that covers my explanation of the website and also the shared decision making and non-discrimination policies which take us through conditions one, two, and three before you move away from the website on the importability page of the 25 top procedures would it be difficult to add a link there to the commercial payers I know that most of them have a site that their subscribers can go to put in their code to get access to what they would be paying would it be difficult to put those links on there for the top few I don't think so I think that would be logistically fairly easy to do on the website we have to check them regularly to make sure that they continue to go to a live part of the insurers website but I think that's a good suggestion so we can incorporate that on the installation before you just go why is the Medicaid reimbursement not included up there you have a non-discrimination by payer policies that's a great question when we look at it it's just not on there because I don't know why it's not on there but we can certainly add it in a lot of the charts that we have been showing throughout we were identifying these three categories but we want to add Medicaid as well so the next condition to discuss is condition A4 which is a transfer agreement of the local hospital compliance timeline has been delayed until before we become operational to give the hospital chance to review our operations closer to opening date condition 5 is that we shall enter a transfer agreement with an emergency service transport for emergency transportation we have entered into an MOU with the emergency squad and I have included that in the materials as well so the next condition is a participation agreement with one or more risk-bearing BCOs the status of that right now is that we have been meeting with one character to talk about what that agreement might look like starting in January we have passed a couple of drafts back and forth and one cares managers and legal counsel have determined that they would need to get their board of managers to approve an MOU before signing one with us so they have been working towards having one ready for their board meeting on April 17th which is next week after that we have that agreement ready for us to sign so I hope to come back to you by the end of the next week with that signed agreement so that you can review it before we start construction and the final condition that we are reviewing today is that we will go from CMS to operating surgery center that condition has also been delayed until we are closer to operational because CMS has to respect our building actors constructed I believe that takes us through the conditions that I am intended to address here today are there any additional questions or suggestions are there questions? thank you public questions or comments? yes go ahead there is one interesting there are two pages where they are talking about the policy and explaining to the patient in terms of the patient dialogue they are actually more friendly in what they have listed I can still get sometimes when I visit a hospital and it's there and they carry through that's far more than still today some of your experiences are when you walk in what you need for information what you are trying to get for information sometimes you don't even know the questions to ask because they are more familiar with the topic than you are and so you'll walk out and suddenly realize something and you had this recent experience it's like why didn't you give me that information because once you realize the question it's so obvious so I'm actually complimenting them if they carry through on what's in those last two that's still something that's very challenging for the consumer to get today and that would be really profound yes just a comment in some ways the presentation was pretty straightforward and almost mundane but the issue itself of the fact that this presentation is made today is really newsworthy this is probably the most contentious issue that the board confronted and as just one observer I'd say this is one of the five best decisions the board has made and even though when you say the board as I remember I had lunch with Con Hogan about a month ago and reminded Con that I always respected his opinion no matter how wrong it was and Con was I think the one vote against the center so I just have to say that although it's contentious one person thinks this is one of the five best decisions and I'm sure there are other people in the room that will have different points of view I was looking at you okay I have some questions or comments from the public if not thank you very much so Todd thank you for remaining in the room sure that's a good delegation so I think we'll do a quick introduction of the panel here and then get into the content for today so my name is Tom Morris I'm the director of finance for One Care Vermont Hi I'm Karen Lee I'm the vice president for finance and strategy for One Care Vermont Good afternoon I'm Sarah Berry I'm the director of clinical and quality improvement for One Care Vermont I'm the director of program operations for One Care so we were asked to come here today and give a little bit of a progress update on our 2018 operations a little bit of a comparison to the budget plan that we submitted last winter also speak to some of the quality and clinical programs and their implementation and then speak a little bit to the 2019 network development and bring up to speak on our strategy and plan moving forward and the items that we tend to cover here are not even attribution across the network the total cost of care and how that may be affected by attribution the effect on risk how the attribution changes affect population health management spending that is distributed out to the network and then an analysis on the impact of budget orders and whether or not we have any concerns with our ability to comply with those orders starting first with attribution the grid in the top left of the slide here has a comparison of the estimated attribution we had in our budget submission last winter until their 122,000 lives we anticipated being in the program programs the next column to the right is the actual attribution as of January 1st and there's some interesting changes to note starting with Medicare we saw an increase in the attribution number by about 6,000 lives the Medicare data we had going into the budget model had a mix of some historical data from Medicare participation in the shared savings programs and some estimates for new participants and we just didn't have great data for those particular providers or communities so it's nice to see an increase in the number and it was a little bit more than we anticipated but good to help starting moving towards some real scale targets one concept I want to socialize here a little bit in regard to attribution is the idea of attrition throughout the year and we start the year with a number of lives in our cohort for each program for a number of different reasons and a various based on each payer people can fall off and become unattributed this is something that we experienced in the Medicaid program last year and monitored the trend but it's a new one for Medicare and Blue Cross in particular Medicare actually supplies with a nice file that had an estimated final attribution at the end of the year that factored in a number of different reasons why somebody may fall off of that attribution roster and their model anticipated that we'd end the year around 35,000 lives which is much closer to the budget model that we built so interesting nuance there for Medicaid about 2,000 fewer lives actually attributed than we had in the model this was basically within the normal churn that we experienced there was an expected number to see a few people drop off maybe not re-enroll in Medicaid or get a commercial plan etc so right in the range that we were expecting we're also anticipating a similar attrition rate about 1.7% per month and that would also bring us down to about 35,000 lives in the year actually the Blue Cross program for the qualified health plan and lives was a lot lower than anticipated 14,000 lives which is a significant drop in transparency we had a couple different numbers along the way the initial modeling data we received last fall or late summer early fall was just try to 35,000 lives we also received a data set very late in December that had about 27,000 lives we saw a decrease from those two points and then when we got our actual delivery attribution it was just shy of 21,000 lives so pretty significant decrease in that program the self-funded program we're still working on the final contract details with the UVM Medical Center so in this number here is still the anticipated attribution and we will be receiving our updated attribution numbers later this month I believe on the 16th the next slide is an updated view on the total cost of care estimates and we'll go back to the attribution attrition fact in a couple of different ways here but the top section has the total cost of care estimates per the Green Mountain Care Board approved budget last winter just shy of 600 million in the recast budget so taking the actual attribution that we have now a couple updates to PMPM targets from payer negotiations and just finalizing certain details that have to be 580 million so about a 20 million dollar decrease in the total cost of care estimate one other nuance to mention here is that in the Green Mountain Care Board approved budget we planned and presented really the high water mark for Medicare and Blue Cross we had a modeled attribution number we applied the PMPMs that we anticipated for those two programs and that was our real total cost of care since then and because we have a couple other data points particularly from Medicare in this recast version I'm applying an attrition rate to each program to really estimate what I think the year end total cost of care number will be and the point I want to make there is that that is a living breathing number the total cost of care target flows with attribution throughout the year so it's always going to be a dynamic number before you jump to the next slide Blue Cross Blue Shield PMPM number from the original budget and the recast budget that jumped yeah that's a good question so in the original modeling data we get our claims feed for non-confidential claims so any claims data kind of substance use disorder comes and we also receive an estimated number for the confidential claims pool it turned out that the estimate that we had last number was really low and the amount of claims in the confidential claims pool has increased significantly it's not a small portion of the spend for any of these programs it just happened to be that that number was materially off in this case so quick update on risk here again because total cost of care is a moving number so too is really the maximum risk exposure is a calculation based on the final low cost of care so as we have patient attrition from the programs which affects the aggregate total cost of care the resulting risk and maximum risk numbers also move so you can see in our Green Mountain Care Board budget we had about 21 million of maximum risk indicated there I also want to socialize two other terms that I'm using particularly with the hospitals to help them understand us a little bit more about one number the quoted maximum risk which takes the attribution on January 1st applies to PMPM targets and annualizes over the year at that level it's being kind of a high water mark for risk what's really going to happen throughout the year is that we're going to have attribution attrition the total cost of care will go down accordingly and so too will their maximum risk so I'm giving them here's what the quoted maximum risk is that's in the contracted denims of each hospital signs but also helping them just with their budgeting and their financial management giving them this estimated maximum risk that does factor in that attrition rate it is an estimate but it's an important piece to note that because total cost of care changes so too does maximum risk question from that population health management spending estimates so a big portion of the one care budget has about 25 million of cost that is paid out to the network to help us with our clinical and payment reform initiatives many of these payments are driven by attribution so as we have these attribution changes so too these numbers will change as well and you can see in the grid below we had our initial budget about 27 million of spending the recast budget 25.5 million so 1.7 million dollar change most of the numbers in here flow just like I said based on attribution for the simple math the PMPM times attributed lives there are really two changes in the model that are just worthy of note here the complex care coordination is kind of our flagship clinical program really trying to engage in the high risk lives of the community we made one modification to the estimated engagement rate just to allow for some ramp up time and not overstate how much we think the network may get for this program and then we've also just updated the blueprint of payments per their financial model for the years a few nuances to those numbers it's not a net change it does change the buckets to some degree so it's one of the point those have overall a little bit of attribution ups and downs that we experienced so they do move the numbers a little bit but not huge changes to the concept of the core idea of any of these programs so I pulled up the budget orders and looked for a few of the items that were financially focused and provided a quick analysis here of my thoughts on them. Order H stated that we must fund our coordination health management investments at no less than 3.1% of the overall budget conceptually because the total cost of care is a moving number the potential exists that that could come down enough and affect the amount of PHM spending but because both are really attribution based we have kind of state in step with the budget order so at this point based on this remodeling I don't see any concerns with us meeting this particular order but there are moving parts to it Order K stated that one care must ensure its administrative expenses are appropriately allocated by state this has to do with the Adirondacks ACO the latest changes do not affect that in any way and we're managing our accounting accordingly the one care's administrative expense ratio must be consistent with its proposed budget this one is a little bit trickier because if we're using the total budget as really the total cost of care plus operations for one care that's a moving number and if administrative expenses stay fixed that ratio can move based on the amount of attribution change we've had it does not result in any real administrative efficiencies I think what would drive administrative efficiencies are fewer communities not necessarily fewer lives so I anticipate our administrative expenses to stay stable but as our total cost of care throughout the year decreases that administrative expense ratio will essentially move so I look forward to working with the staff really just to make sure that the measurement for this particular order counts for any of that total cost of care movement that we expect to see throughout the year and then Order M is that one care administrative expenses should be less than health care savings generated for the all payer model again because the total cost of care and the potential savings there is a variable number it potentially could affect this order but at this point in time and I also want to work with staff on this to understand the exact measurement a little bit more but at this point in time I don't think the magnitude of the changes to the total cost of care provide any real concern around this order but it is one that just has enough moving parts that I think we should make sure that we're in sync with exactly how to measure and just confirm that as a group so that was the financial piece unless there's questions I'll hand it over to Sarah just a couple questions even the fact that the total number has gone down because how does that actually work with the hospitals since they've built their budget based on receiving a certain amount from one care and then when you actually get the attribute device there's a change of 20 million in total so how does that work in communication with the hospitals and with their annually after that process? Yeah good questions really the budget impact of the hospitals is mostly a shift between fixed payments and fee-for-service and not necessarily a net increase up or down in the material way that could be a little bit of movement there in terms of overall feedback from the budget process and communicating the fixed payments it was a tough thing to deal with last fall as a lot of information was evolving this year having the fixed payment model up and running for Medicare as well I think it's going to make the 2019 transition a little bit easier especially for those who are currently accepting those fixed payments and we can help the hospitals model and project that split of the fee-for-service to the fixed payments but a little bit of movement here so particularly for Medicare which is going to be a hospital focus dominated spend with more lives in the one care program and more of their spend for one care attributed lives that would increase the, potentially increase the amount that they expected to have in their Medicare fixed payment So do you have a chart here when you were preparing the budget there was a chart illustrating what each hospital was going to get from a budget point of view and do you have that same time? We do And then I don't know if you're going to, I didn't see any notes but you know reinsurance and if anything happened with the reinsurance or the reserves that we had just set up? Yeah I can speak to those reinsurance I'm actually still working with our broker and potential reinsurance to see if we can get something in place the latest there is that we're engaged with a potential reinsurance partner who waits for the claims fee to come through in the next year and then kind of sets the target accordingly The challenge that we face, there's challenges, one is that it's not a mature market to begin with so there's a lot of education that needs to happen with the under underwriters and reinsurance. The other tripping point that they find is that through the Vermont all payer model we have a departure in certain areas from the standard next gen program So some of the reinsurers are starting to understand the regular out of the box next gen model and program and tailor reinsurance plans to work with that but we have some changes with the way that the target is set and the way the trend rate is applied that just results in an additional back and forth to explain it and that's one of the challenges we're facing but it's not over we're still working with them to see if they're willing to move forward and make a proposal and then evaluate whether or not we think it's a good buy for one care network. And then in terms of building reserves, working on that it's a trickier problem than one might think. There's some interesting tax implications, potential tax implications to it that we want to make sure that we circumvent and also want to make sure that those contributing to the reserves have certain reasonable protections about the money that they're putting into one care while also complying with the spirit of the budget order. So working with council a little bit to kind of navigate those accounting and legal waters to make sure that we can build these reserves in a compliant way and that's fair enough. Director of clinical involvement and I thought I would take you through some of the examples of the work that we've been focused on in the first few months of 2018 and give you some highlights as to what will be coming over the course of the summer and fall. So to begin, we had a fantastic partnership in 2017 across a number of organizations so One Care, the Blueprint for Health, the Health Department SASH, our Queen Quo that really united all of these organizations behind a common aim in terms of quality improvement opportunities and what we were providing to the network. Both the One Care Network but also any other interested provider in the state and so that initiative was focused last year on controlling hypertension and so this year we really took the learnings from that initiative again expanded that partnership and used the subject matter expertise across our network and the data that One Care and the Blueprint had to determine that one of the opportunities we really wanted to leverage together in 2018 was around both diabetes management and diabetes prevention and so you'll see that is the focus of a year long learning collaborative that we are just in the process of launching. We actually held the kickoff calls for providers and their teams just at the end of last week and so that initiative was open to any practices or other continuum of care partners in the state. We had 16 different organizations sign on which is an increase from last year on the controlling hypertension which was I think 10 or 11 sites and we are going to continue to evolve the learning process and structure but basically we will be offering monthly coaching and feedback sessions around the data that we are collecting. There will be in person education and training sessions. You can see the dates and the topics here really around appropriate identification of individuals that might be at risk for diabetes or are already in diabetes management whether that be self-management programs or medication management and then how we can successfully identify panels of patients through their primary care office and better support them in the provision and access to care and services to education, training and the prevention based care that we would like to see as well. So you can see on the slide a number of the measures that we will be supporting and they range really from looking at basic vital signs, high weight, blood pressure and such to also making sure that individuals that do have diabetes are getting appropriate lab tests, that they are getting eye exams and other services to do everything that we can do from a healthcare system perspective to ensure that they are getting appropriate and timely care and having quality outcomes. The second thing that we have really focused on and are moving forward is an interdisciplinary partnership around clinical education and training and so we model this on a fairly traditional academic grand-ground style educational session and then we ramped it up a bit because of the unique leverage and opportunities under One Care's diverse network and so what we did is we made a commitment that anytime we do a interdisciplinary grand-ground we'll bring together a panel of individuals that represent a broader perspective that have subject matter expertise perhaps from primary or specialty care but also from a continuum of care partner such as home health or a skilled nursing facility or bringing in our health department partners as we did with palliative care session late last year and we've received tremendous feedback from this that really the interdisciplinary nature of understanding the entire course of care that a patient or a family is experiencing and understanding where some of those communication challenges exist where other expertise exists and can inform that care process has been tremendously helpful as to have been the identification of some of the variations that exist in different pockets of the state whether that be in available services or treatment options and so we're receiving tremendous positive feedback on this and you can see some of the topic areas that we plan to focus on later in the year we just had a session on dementia we'll actually have an intensive chronic care management focused on constructive excuse me chronic obstructive pulmonary disease and then later in the year bringing in some additional work around patient and family centered care as well as a pediatric team focus work that we've been concentrated on in the past few months it's really about improving both the collection and quality of the data that we're able to obtain and then how we can share that more interactively in a more timely manner across one care's network and so some of the things that we are very pleased to be moving forward the first is a partnership with the blueprint and one of their vendors called Capital Health Associates and they've been engaged with vital for a number of years and something called data sprints really this is about identifying gaps in clinical data and how that flows into vital and then to be accessed by organizations such as One Care in order to improve the identification of gaps or opportunities and so One Care is formally joining that process to ensure that we can have focus areas that align with some of the priorities that our providers in the network think are most important or most accessible for us to be able to improve the quality of those data needs. We also to the point that Tom made earlier about confidential claims and the difficulty of understanding kind of what's in that black box we're very pleased that in partnership with the Croskow Shield we are moving forward on a process where they're going to be able to share some aggregate data with us on a quarterly basis and that is much more than we've been able to see to date and our providers are very interested in then being able to get a better handle on the frequency with which they are or are not meeting some of the quality measures that we are responsible for as an ACO and Vermont accountable to under the all payer model and so we're expecting that first feed coming shortly and then are working on a process of how to communicate that amongst our network. One of the other big things that's been happening for us in the first quarter is our annual quality measure collection process and so this is an event that takes us roughly 8 to 10 weeks to collect data that are clinically based measures that cannot be abstracted via claims data and so for each of our payers there are a number of measures and those do vary by payer but one payer has dedicated nursing resources, professional coders to work with our entire network to collect those data manually and try to reduce the burden of the sites needing to collect that information and send it to us. We've had tremendous success in the past couple of years in gaining efficiencies around the process around the tools of how we actually collect that data and also around being able to access some of that data remotely to create some efficiencies rather than spending some of our time in cars traveling directly to sites. So those data were submitted to each of our payers in 5 of the deadlines which were earlier in March and we will be waiting to receive the final information back on our quality measure performance which we anticipate will come in the summer. One of the other things that we've been actively working on in partnership with the board and with the healthcare advocates office is around the quality measures assessment process under the all payer model for 2019 in the Medicare program and so we've been actively discussing gathering feedback from our network as well as having conversations about how this aligns under the all payer model and I think that negotiation and discussion has been moving forward very well and very collaboratively. In terms of care coordination I feel like this is often the topic that I spend the majority of my time talking about so I've minimized it a little bit here today but of course I'm happy to answer questions in terms of the first quarter we've had some major milestones the first of which is that we were successfully able to expand that program that really began with Medicaid in 5 communities to now 10 health service areas across the state and in doing so we were able to bring all of those attributed lives that Tom was speaking to earlier through a risk stratification process to give us the first signals and early identification of where those individuals are that could potentially benefit from enhanced care coordination services. So all of that information has now been generated, is processed, is in care navigator, our care coordination tool and our communities have been trained in how to access that. We continue to train users particularly in the newer communities that joined OneCare in 2018 in Care Navigator as a tool and we have about 150 or slightly more than that new users that have joined in this last quarter. And then the other thing that has a tremendous focus for us is that we recognize that we need to do some work again in partnership and building on the work that the blueprint has done around enhancing the skills for care coordinators across all organizations that are interacting with patients that are attributed to OneCare. And in doing so we actually made the commitment to think proactively about those communities that might not be a part of OneCare this year but that might be interested in the future. And so any of the core skills for care coordination trainings that are not specific to the technology are open to any interested parties in the state of Vermont. And in doing so we've held, I think the number is somewhere in the neighborhood of 24 different training sessions. We've trained, it says 200, I just checked with my team and they submitted a report this morning. It's actually more than 400 individuals now that we've ended that quarter. And those are on a variety of skills. So it's the basic concepts but also advanced concepts in how to use specific tools, how to communicate more effectively. And then one of the things that's been most interesting is a senior leader training where we're actually bringing in senior leaders of various organizations and addressing with them some of the challenges around workforce development burnout. How do we talk about interprofessional collaboration when it comes to different roles and responsibilities for care coordination say the difference between nursing training and social work training or more as a mental health counselor. So tremendous work there. We're continuing to evolve those trainings moving forward. I just wanted to highlight several other specific initiatives or information that's being shared across our network. The first is Rise of Vermont and we're very proud of that partnership and the evolution that is happening right now across communities to take a movement and an initiative that started really in one of our local communities and spread that. And there's a lot of public will, they're doing some really exciting things to spread the word not only among the organizations that might want to partner around Rise of Vermont but really out with Vermonters so that you can see and feel what this initiative is really going to address in terms of health and wellness and the promotion of these services across the state. We have an innovative pilot project going on right now in partnership with Howard, the designated agency in County as well as with SASH and this is an opportunity that One Care is funding where we are providing the support for a Howard Hyatt mental health clinician to be co-located in two housing sites, two SASH housing sites and this individual is their full time to be able to support mental wellness and so she provides both education group education opportunities, one-on-one assessments and referrals to more specific counseling as well as really helping evolve the culture and the environment both for the staff at SASH but also for the residents around really recognizing what are some of the warning signs that somebody may be having some challenges or some difficulties and might be able to benefit from some services. And what we're seeing in the early days of this pilot is that there's a better use of upstream services and we don't have definitive data for you. The underlying kind of outcome measure that we're interested in here is reduction in utility utilization and so we'll be watching that over the course of the rest of the year. And then finally we have community network success stories. This is a tool that One Care puts together. I believe we've shown some of these visually to the board in the past and I just highlight the diversity of some of the topic areas and the communities that these are coming out of. We are committed to continuing these over the course of the year and they really are a source of pride in local communities around the work that they're doing and the avenue to be able to share that in a way that is very packaged, concise, and able to be translated to others across the network. So I'll stop there and I'm happy to answer any questions. So questions from a really easy group. We turn now to network development. Here we are. So for the year 2019 we're actively in our planning stages for the entire contracting cycle and currently we're in the process of sending out our letter of interest to all of the people that are currently in our network as well as those outside of the network to ensure that we are giving everyone an opportunity should they choose to join One Care. In terms of creating some guidelines around our programs what we have put forward is that for hospitals they are the ones responsible for risk and therefore what we've said is that if there is an existing hospital that has participated in one of our programs we would intend that they join all of our risk programs for the next year. If they're new to risk if it's a new hospital to our network then we would like to offer them the ability to participate only in the Vermont Medicaid next generation program as kind of an on-ramp into getting acclimated to what it means to be in a risk based program. As far as the other parts of the continuum we give those folks the option to participate in whatever programs the hospital is participating in so with the hope that hospitals are primarily participating in all programs that allows anyone else in that network to also then participate in those same health service areas again and that's because the hospital is taking the risk. So I think that's good for that slide. So for us to meet our all payer model scale targets we are looking to increase the number of attributed lives that are under a value based payment arrangement which is why we're really trying to reach to not just those that are currently participating in our network but any other hospitals or PCPs or anyone else in the continuum who would like to join one care. As far as some of the key elements and guidelines I'm getting signals from the audience they're having trouble hearing. Oh, I'm sorry I thought I got it close. Can you hear me now? Okay thank you for letting me know. So in terms of some key elements of our network development plan we do want to welcome new entrants especially those with attribution but really that continuum. We want to develop some clear programs so we have some programs that are very clearly delineated for hospitals and for primary care as an example and we want to start looking at other types of programs that we can offer that make sense for other parts of the continuum to get value as part of our network. We're beginning to engage with new provider types and what we have considered is that since we don't have endless resources to create programs for everyone much as we'd like to we would like to bring some engagement into our process of program development such that areas like physical therapy, occupational therapy chiropractic we would like to bring them into a forum for collaboration and to engage with them on the development of a program that is co-designed so that we can then offer that in a later year and so that's something that we were really interested in as we got some input from our provider communities that although we'd like to have everyone join there has to be a reason to join and we want to make sure we're meeting those needs and that those needs are helping one care further their mission. As far as border hospitals we are deferring those out of state hospital programs until 2020 until we can come up with a mechanism for dealing with the risk aspects of a hospital such as that and then as far as any new program offerings if there are some new programs that need to be developed for a new part of our network we do want to be very intentional about bringing that through our board and making sure that we're sizing and scaling and thinking it through as I said with input from the provider communities but also to make sure that that's something that we can scale to and be successful with in the future and this next one is our last slide. We've been doing a lot of very detailed planning this year on what our contracting cycle looks like and one of the ways that we're trying to improve things this year is education so what's not necessarily outlined here looks worth some discussion is that we want to make sure that especially for new entrance that we're able to share with them what we've learned about our programs over the course of this year to date and what that might look like for them next year so we want to be able to give them a more detailed education on what it means to be in the one care network what the expectations are and then what value there is for them to participate with us so this milestone chart is a way for us to at a high level outline some of the key milestones that we are held to in terms of backing into our budget submission and our Medicare rostering process that we are held to for the final submission of lives through that program so currently we are in the process of reaching out to all hospitals FQHC's primary care and then the continuum to ask for those that are interested to give us an indication of that interest and that has huge downstream positive effects on especially Tom and his budgeting and modeling so we really want to make sure we have the most accurate information on attributed lives early on so that we can do better modeling with the best available data that we have and then that will help us with the remainder of the cycle in terms of education preparing our network to be onboarded and prepared for 2019 Anyone have any questions? Any questions from the board? If not we'll go ahead. Are you really preparing any reports that you're sending to the board looking at the budget? You know we have a process where we go to the hospitals where they look at their roughly actual and talk about any variances and see if that process has been set up? Yeah we have a quarterly financial P&L reporting plan in place just enough runway for us to close the first quarter and how to go through with the board approval cycle but we will be sending that to staff and the earliest availability should be quite soon and then you can compare there What one thing to forewarn is in our budget presentations last winter with an illustrative P&L that showed the 600 million the total cost of care not all that shows up on the real accounting treatment but it will give you an idea of how real spending is comparing to plan. Thanks Any other questions from the board? If not we'll open it up to the public for any comments or questions on anything that you've heard from the Team 1 Care. Susan? Actually I had an end of it before you gave that modeling and you had questions regarding anything that you heard. I actually have questions about something I haven't heard anything about and can't find any information about on your website which is some of the waivers that are available for patients for the attributed lives in the Medicare next generation ACOs. Some potential benefits to patients are that you might not have to spend three nights in a hospital or you might have greater access to some follow-up care telehealth home visit. I'm wondering if you could talk about the status of the implementation of your waivers in particular the three days stay one and where I might be able to find an implementation plan you're supposed to have materials to give to patients so they understand what's going on etc. I've looked on your website for those things and haven't been able to find them. So any updates on the implementation would be great. Thank you very much. We have spent the last couple of months being able for the first time to access detailed information from CMS about some of the operational details and requirements for reporting and data collection associated with those waivers so there was definitely an intense kind of research and learning process that we've been going through. We then had some discussions through our clinical committees about how to prioritize the waivers because frankly we didn't feel like we had enough capacity to do them all at the same time and do them as well as they need to be done and so the direction we received from our clinical committees was to start first with a SNF three-day waiver that you were describing and so what we've been very actively working on there are first to identify pilot sites and we have identified Did you say the skilled nursing facility? Yes, sorry, skilled nursing facility. This is the waiver of the three-day inpatient stay requirement for skilled nursing facility entrance. So that will be the first waiver that we implement and I would say that it's coming quite soon. We have three identified communities that we'll be piloting that in so think about that as a dyad between a hospital and a skilled nursing facility potentially more than one. We are in the final stages right now of creating what we call a resource manual which is a very detailed workflow that gets to the supporting documents that you were describing. So there's tremendous need in order to effectively operationalize these waivers to get the process right. So that begins with how do we identify individuals that are eligible for this waiver because not everyone who shows up at a hospital is a trivigile one care so making sure that that's an effective process and then that there are appropriate trainings for the staff that will then interact with the patients to be offering these benefits and that requires educational tools and resources, a lot of frequently asked questions, so we're developing all of that and then the workflows that are associated with it and then the data tracking and evaluation of the outcomes. So I have to say we've learned a lot it's much more complicated than we had first envisioned. Providers to help on our clinical initiatives, those are kind of the variable pieces that the administrators spend. Especially with attribution change of this magnitude, there were some kind of material changes between Medicare and Blue Cross going down but in total not enough to derive any significant operating expense moves. Any other questions or comments? Thank you very much for the excellent presentation. We had a great presentation from some of your colleagues this morning and this afternoon really makes that complete, so thank you. At this time at Pat, Nina can come down and introduce the discussion we're about to have on all of you. Talking about the three high levels, those three goals as you are familiar are to increase access to primary care, to reduce the prevalence and morbidity of chronic disease and to reduce deaths due to substance use, overdose and suicide. And to that end the model is very innovative and contemplates a bridging of what we think of as the traditional medical care continuum and the public and population health system in our state. Said another way, we can't make progress on those high level goals without there being a partnership between the state of Vermont and the medical care continuum that is being regulated as a part of this model. We've asked Beth Tansman from the Blueprint for Health and Commissioner Mark for being from the Vermont Department of Health to talk with us today specifically about the efforts being made to confront the opioid crisis in the state of Vermont with interest in working more on how you can make progress on the high level goal of reducing deaths due to substance use overdose. And Pat's going to talk with you specifically now about the substance use disorder quality measures in the model and what's required to make progress there. Thanks, Dana. I'll just take a couple of minutes here, but I really did want to get a little bit specific with you about what some of those quality goals are that we negotiate with our federal partners. The quality framework in the all-payer model has 20 measures and seven of those or more than a quarter relate specifically to substance use disorder treatment. Showing how important that issue was not only to the state of Vermont but to our federal partners and the real desire to make some progress in this area. So you can see the seven measures listed here with the highest level one being effect on reducing deaths related to drug overdose. There are some measures relating to initiation and engagement of treatment. There is a measure about the numbers of people in Vermont receiving medication-assisted treatment for opioid dependence. Some ED visits first of all the rate of growth in mental health and substance abuse related ED visits. And then is follow-up occurring within 30 days after someone is discharged from the ED. And then looking at our Vermont prescription monitoring system, are providers using it? So what's the number of queries of providers who have written a prescription for an opioid compared to the number of unique recipients receiving an opioid prescription? Within the agreement we specifically negotiated target rates. And they're very ambitious. And I'll just use the first one as an example. We negotiated 10% reduction in deaths related to drug overdose as part of the agreement. So there really was a desire both by us and by the federal government to see some progress. It's a little too soon to tell. We're really in the first performance year of the model right now. But we're seeing some promising figures already. And knowing that one year is not a trend, I just want to note that for 2017 preliminary data is showing that there's a slight decrease in deaths from drug overdose. So we'll see how the final data looks. But that's an extremely encouraging sign after some years of seeing increases. And similarly the medication assisted treatment measure our data, our most recent data actually shows that we have achieved that target. So we'll see if we can sustain that as well. But by way of introductions, our guests, I just want to say that the work that the Agency of Human Services is doing, the blueprint for health of the Vermont Department of Health this is nationally recognized work. And it really speaks very directly to these measures that we negotiated for this agreement. So I'll stop there and ask our guests to come forward. I was just going to say good afternoon. Mark is still apparently at the State House with this opioid awareness day in the Governor's announcement. And so I would be happy to work with his slides to help get started. Which is something that, by the way Beth Tansum, Vermont Blueprint for Health, it's usually a disastrous idea to try to present all those slides that someone else has developed. And also I should say, in all fairness, I'm a social worker not a physician. Mark might like it though. We did work on this presentation together, but part of what we wanted to do was to set the overall national context of what we know about and are learning about what we now refer to as the opioid epidemic. To look a bit about how that epidemic has been playing out in Vermont. So we want to look at information about overdose deaths and prescribing and drug use patterns across all kinds of different substances. We'd like to introduce the key anchoring concepts that a high-function state response might look like to address an opioid epidemic. We'd like to discuss what we're doing in Vermont, both currently and future in the context of what we would call really a four-legged stool. That includes prevention, of course, intervention and treatment, enforcement, and recovery services. We'll talk a little bit more in detail about the Hubble Spoke initiative, which is our medication-assisted treatment initiative for Vermonters with opioid use disorder. And then some overall highlights of where we are in planning some new major initiatives. And God bless him, Mark developed a 54-slide presentation here, which is a whole bunch of slides for a one-hour. So talking a little bit about epidemiology, if you will, of substance use disorders in general. Substance use disorders are common conditions. About 21 million Americans have a substance use disorder and so that's actually comparable to the rates that we have individuals struggling with diabetes in our country. So it's very consistent with rates of diabetes. And it's actually more common than all types of cancer combined. So when you think about conditions that are important to address in our healthcare systems, substance use ought to be sort of front and center in what we're doing. Many Americans report misusing prescriptions for pain medication. What that means is that they're either not using it as prescribed, or using someone else's prescribed medication. Of those, we have about 2 million people who report to be dependent on pain relievers. And we have just over half a million individuals who are dependent on heroin. What is, I think, of concern to any high functioning system is that very few people who struggle with substance use disorders actually come into treatment. Nationally only one to two of 10 people with a substance use disorder actually receives treatment. That's a serious issue that we all need to work together to address. Drug overdoses in the United States have actually overtaken our other major causes of accidental death in their incidents. It's overtaken car accidents, guns, and HIV as a leading cause of death. And drug overdoses are one of the leading causes of death for adults under the age of 50. The very top large overdose death rate of 64,000 overdose deaths that happened in the United States in 2016 is extraordinarily high, not only very high, but you see it's very much rapidly increased in the last few years. It's a staggering figure of 64,000 Americans dying of overdose death rates in one decade that would entirely empty out the entire population of the state of Vermont. Clearly one of the major things driving overdose deaths are actual heroin overdose deaths. The heroin is a little harder to read the colors in this but it's the middle line that had stayed stable from 1999 through to just about 2010 and then you see it begin to spike up in 2012. Part of what is beginning to happen is that as we gain better control over prescribing opioids, people with dependence are then converting to using heroin. And the issues in terms of overdose death rates when you're using heroin are purchased on the streets that you don't know what's in it and so it's much more likely to be lethal. I'm sure the doctor would have more to say about this slide. Vermont, for all of our attention that we're focusing on overdose death rates, actually has the until happy distinction of being about nationally average. Part of what's interesting about this map is that the very darkest colors like the dark blues reflect the highest overdose death rates. And what you see here is that this heroin or opioid epidemic is actually a regional issue. It's not nationally all the same in every state. So we have concentrations in the northeast and the west in some areas of the southeastern United States and then again a little bit in sort of mountain central areas. It's not evenly distributed. In this map Vermont is actually about average in terms of overdose death rates and many of our neighbors surrounding us with the exception of the U.R. are actually higher than state than national average. That rate by the way is probably a little difficult to see here is the national average rate is 19.8 individuals per 100,000 of the standard population. This is a slide that tells such a happy, unhappy story for Vermont. These are the New England overdose death rates. We're comparing ourselves more to our regional peers. And Vermont is the lowest darkest line. It's such a happy story. New Hampshire is the top gold line. You see the incredible spike in the rate of overdose death rates in New Hampshire. So the part of this picture that's positive is it appears that Vermont is experiencing a lower rate than our neighbors. It's all still way too high and not a good story at all. It's possible that the investments in the treatment system that we began in 2013 in Vermont have had an impact on helping to reduce the growth in our curve in terms of overdose death rates. But you see even in Vermont by 2015 we see an increase in overdose death rates and a lot of that seems to be driven by the introduction of fentanyl into the heroin supply. And that is an extraordinarily lethal opioid. And it's difficult for people using it to know how much is actually in the heroin that they may be using. So we have a high rate of accidental death rates. But look at the spike throughout New England from just since 2010. This graph is from the Department of Health and describes the actual contribution of different types of opioids to the overdose deaths. The black for the darkest part that's the highest in 2017 is fentanyl that was 67 deaths were attributed to fentanyl 67 over 101 opioid overdose deaths. The purple line 39 is heroin and the green line shows what our overdose deaths from prescribed opioids. So again what you see here is that prescription amyly was clearly a part of the driver of this epidemic. Some of the lethality is associated with fentanyl and heroin. Is it self-reported or these are an autopsy result? This is autopsy. The other complicated factors is that many people who had both fentanyl would also have some heroin in their system. So often people have multiple drugs on board but this is an attempt to try to tease out if there's any particular pharmacologic agent that's particularly driving the death rates. And we're seeing that experience with fentanyl. Again let me help orient you to what you're looking at here. This is a complicated but wholesome picture of trying to understand of those people who report misusing a prescription amylyver where did they get? The blue portion of the pie on the sort of upper left hand side reflects said people are recording I got this prescription from my doctor so it's a prescription for me from my physician. The misusing is implying that they did not use it as prescribed so they might have taken it more often and more frequently or in higher doses for instance than I had described. The sandy section of the pie which is the largest part is reporting that people who said while I misused an opioid prescribed opioid where I got it from was a friend or a relative or I stole it from a friend or a relative and then the smallest part is the second time I was smart is that I actually bought it from a friend or relative. So the full half or more than half of all of the opioids that were misused the source of them for people was from friends or relatives not from direct prescriptions. This is part of why the prescription give back programs and the safety and security of prescribed medications is just so critically important. You see this is this pathway that opioids are becoming available to the public. This is again from your this is a complicated graph in that it's trying to show the amount of use so as you move from the left hand columns to the right hand columns indicate people who had more frequent use. The farthest way is saying I misused opioids for 200 to 365 days of the past year. So in other words I misused opioids for most of the days of the year and in the very far left column it's people who report having misused opioids only for about 1 to 29 days and they're again looking at the sources of where it is that people got the opioids that they were using for these non-medical uses and the darkest blue are the ones that were prescribed by physicians and then the next lighter blue color is given by a friend or a relative for free and then next in gray is bought from friends or relatives. I mean this is the point here is that for people there's a wide continuum here if one of us is injured and a family member gives us one oxycodone because of a sprained ankle or whatever and you use that once or twice that's a far different potential issue than if you are misusing opioids between 200 and 365 days of the year. So we're looking at a spectrum here and one of the things that happens is when you get into more frequent use you also discover that the difference in where people are getting their non-prescribed opioids flattens out from basically any source where they can. So why are you dwelling so much on this issue of opioid prescribing in part because there is a direct correlation between the amount or the number of morphine hologram equivalents which essentially refers to the strength of an opioid prescription. There's a direct correlation between the hazard of having an overdose and the strengths of those prescriptions. So again let me orient you to this picture again a different kind of view of understanding this epidemic. These are opioid prescribing patterns related to two types of pain that we commonly use opioids for. Acute pain meaning injury and chronic pain in other words long-term use. The red, red for far, are for acute pain. The gray reflects chronic pain. And then along the x-axis is the amount of morphine equivalents being prescribed. And what you see here is this red that he had is that the hazard risk of an overdose death greatly increases with a higher rates of NME equivalents. Oh my goodness the doctor is in the house. Let me pause for a moment and give Mark the opportunity to come and join us. Thank you. I had to participate in a history in the making. You may have heard a few shakes. We've heard nothing. We've been sheltered over here. The governor was signing his of the three gundams. It was a rather large crowd. Some four, some against. I thought it was truly a momentous occasion and a public health issue. I've been whipping two years. I don't know how much. This is good. I was starting to orient people to what the slide shows. You can tell us what it means. We're out of speed dating. Oh yeah. Bottom line is this X-axis is a morphine milligram equivalence which is just a measure of how potent the opioid is that you're giving the patient. How many pills, how many milligrams of a certain opioid and how they equate to morphine which is the standard. So needless to say if you're on a higher dose and higher potency you have a higher risk of death from an opioid overdose. So this gives us a little context as to Vermont's performance with regard to the rest of the country. The concerning features here is that if you look at our teenagers this is in white so they have amongst the lowest rates of past year pain reliever use. But when you get into the ages of 18 to 25 you're at the top. We kind of consider the ages teenage and young adult as where the brain is most susceptible to addiction and where those are our most vulnerable citizens if you will when it comes to this crisis. Good. If you look at heroin use former Governor Shumlin got us on a vat and got the country cured up for this because we're one of the states in red where we have the highest amount of heroin use. That is noteworthy because the northeast and Appalachia are really where the peak of the epidemic is so nobody is sheltered. In spite of having such a high rate of heroin use we have one of the very low rates of perception of harm from heroin. So simplistically if you try to put everything together as to how we get where we are we have wider availability of prescription opioids because doctors were actually charged with treating pain and making sure that everybody was satisfied with how their pain was treated and pharmaceutical industry was actually deceiving doctors in some ways and talking about the lack of addictive nature of some of their drugs we had basically economical changes that made it easier for someone to transition from abusing prescription opioids to going to heroin because the heroin was a much better economic proposition and at one time, but not now, we have problems with access to treatment for opioid use disorder so you put that all together and you end up with the crisis we're in but not to make it that simplistic, there's plenty of biological and social determinants of health risk factors that predispose certain individuals to substance use disorder with all of the above just compounded upon. From interviewing people in our current treatment system it's become very obvious that in the teenage years many of them would say they began with tobacco, alcohol and cannabis and then they'd evolve more time to the stimulant drugs on cocaine then around 20 he began with prescription opioids but not using them responsibly and then moving on to heroin and everything else so this is a stereotype kind of slide that actually is very typical to not ignore the fact that heroin is not a drug problem, but clearly when you talk about death rate it's clearly high up there but for what still has a big issue with alcohol use, this is from ages 12 through a thousand just regular substance use in the past 30 days alcohol, marijuana and then non-nickel use of pain relievers and then down to 0.8 heroin every substance that you have a problem with compounds the problem and makes it more likely you may end up with an addition to heroin so these things are very multiplicative if you want now to get to remote, that sets the context a few years ago the National Safety Council said we were one of the top four states when it came to our response to the opioid crisis and they said that because they assessed all of these areas and found us to be doing really good work, the mandatory prescriber education prescribing guidelines for clinicians, drug monitoring programs access to the lock zone and treatment available, pill mills wasn't really a problem for us many states don't have that as a problem so what we're going to do in the rest of the slide is lead you through elements of what we call a high functioning state of response to the opioid crisis and we'll weave you through the sort of four-legged stool of prevention and treatment and intervention in the cover without going into enforcement this slide is just to show you that we actually have a really good state when it comes to the governor being alive with us all across state government people are alive with doing something about this problem in a very constructive way and even now federal funders are actively alive as well so support at all levels is critical and you need a health department and state government that really seeks data, looks at data, analyzes data and uses data responsibly to enact policy change so in prevention if you have a state that's doing right things and we're going to brag about ourselves by the way but we're also going to show you where we have work to do you want to have education but education is always one of those necessary but not sufficient items so you've got to have more than that but clearly a lot is happening for education at the prescribing clinician level, at the medical student and graduate medical education levels prescribing rules and prescription drug modernity systems so the prescriber rules are based on the thesis that four out of five heroin users say they began by abusing prescription drugs and that of those who abuse those drugs seven out of ten received them through methods of diversion not because they were prescribed to them necessarily and their prescribing habits traditionally have been giving too many pills of too high a dose for too long a time and that needed to change some of the data behind that and this is one slide out of a million but this one will show very nicely if you look at the day supply of the first opioid description and the probability of continuing to use it several months later in this case one year and in this case three years later it's really about the third or fourth day that makes a big difference and someone potentially still being on that prescription a lot longer than it was prescribed for. If you look at the number of prescriptions it starts at the second prescription so pretty amazing data that was not available years ago this is data that's been available within the decade we're in now so we have a prescriber rule that from my standpoint the biggest thing it does is create conversations between clinicians and the people that they're seeing in their office so that the entire menu of alternatives for pain management are discussed that the individual knows that opioids are part of one pharmacology but there are other pharmacologic methods and there may be non-pharmacologic methods the prescriber rule also includes discussion about how to store these and dispose of them when you're done with them so your teenager doesn't find them during the party and distribute them around to their friends and patient education mandate and informed consent I'm not going to bore the group here with details about every bit of the rule just to say that this is something that was never done until the last year or two where we actually give a listing of commonly associated injuries, medical conditions surgical procedures and the expectation of what kind of pain management might be required for those from ones where maybe no opioids are needed like pulling a tooth to ones where a person could be expected to need quite a bit of opioid and a post-operative period from a very complex or repeated procedure and we've given them clues about the number of morphine milligram equivalents what that would equate to in terms of commonly prescribed opioids it's really been a revolution and something that most doctors will candidly admit they were poorly educated on pairing that with a prescription monitoring system that statewide that allows you to have a database of all prescriptions written for these drugs that allows pharmacists to really understand who's going where to fill these prescriptions that provides a clinical tool for preventing diversion and abuse of drugs and a surveillance tool where we can actually tell clinicians what patients going where for what prescription fill are they getting it from other doctors what is their own prescribing habit and they have outlier and way overboard in the opioids they prescribe compared to others in their same field very powerful information and that's mostly for acute pain we pair that with CDC guidelines that essentially say to be oversimplified opioids don't get used for chronic pain management and here's the results in one way of portraying the data which is total NAD of opioid analgesics per 100 residents 2017-2015 drop from 77,000 to 57,000 more importantly though the prescriber rule only went into effect July of 2017 so from here to here a further drop in a trend that was already beginning because people were already cognizant of the problem and we anticipate this is going to continue to drop down other parts of a high functioning response to the prevention area have to do with all the time prevention messaging campaigns the important thing here is these are carefully targeted to the audience of importance sometimes that's teenagers sometimes that's young adults sometimes that's adults and it's targeted to the media that they commonly use so you may say I've never seen one of these and it's because you maybe just watch TV and you aren't engaged on the social media that people in the age range that the messages targeted towards again we also have school based primary prevention programs that involve curriculum but also substance abuse professionals in schools and then community programs coalitions like dark and St. Johnsbury and CCOA and Burlington Project Vision in Rotland and then a whole area that we're very interested in now with all these alternatives to pain management because that's where we prevent the writing of a prescription open this is just an example of some of the health departments many many messaging campaigns I'm not going to go into detail on the purpose of this conversation but some of them may look familiar to you and again some may not and then there's plenty of other things that I'm not going to spend a lot of time on Paradox is an actual program that parents can go on a website and learn how to have conversations that they never thought they have to have a lessons about these issues we have academic detailing which is actually doing what the pharmaceutical representatives do in a doctor's office but doing it with academic people who can talk about dedication use and evidence based way and other things I've mentioned highlighted here are the things we feel we still have a lot of work to do with the non-highlighting and we will do it very well. I'm going to just go into harm reduction before I hand this off back to that harm reduction strategies are critical to managing the opioid epidemic and they do cost money like everything else so ways to dispose of drugs right now you all hear about take back days things of that sort they need to be really much more user friendly we need a 24-7 system where you can drop the drug off anywhere you need to and want to not have to wait twice a year to see some van come to town or bring it to your police station or stay trooper barrack where most people don't want to spend much time Sharks selection and disposal programs are a real important public health initiative as you know from the news we distribute naloxone everywhere we can all first responders have it in addition to the number of public who get it for free or if they want to go to a pharmacy and use their co-pay they can also get it there because there's a standing order that I sign once a year that allows naloxone to be given to anybody who walks to the door essentially there's also a good Samaritan law so your best friend or family member can use this naloxone on you if you happen to be lying down on the ground reading a book without that feeling like it could be a repercussion than maybe it could be Syringe services programs are places people with opioid addiction can go and exchange needles, exchange syringes get education about safety, get testing for HIV or hematitis and also have a human being who can actually talk with them and if they happen to be ready to go into treatment and that life ball has gone off that person can then help them get ready access to treatment. The Syringe Services program has also distributed naloxone that entertain people with their use and then of course alternative subcarceration so that we don't lock up people to get out of this epidemic we actually have to address it from the public health framework so family courts, drug courts, and so on. Somewhere over 20,000 naloxone kits have been distributed in not too many years and we know that at minimum we had at least 1,200 overdoses successfully reversed some people who potentially died and that's underreported because the people in the public aren't necessarily obligated to report to us that they use the kit to save their life whereas the first responders they do reclaim everything. And this just shows the number of syringes distributed by year and the number of people who are actually attending these Syringe Service programs we're still on a steady uptick. And that's a good thing even though you might look at it as a bad thing and why so many people still need to have the service it's a good thing they're accessing the service. So we think we're doing very well in our reduction strategies but the Syringe Service programs really need to be markedly expanded and there's a whole lot showing on in the law enforcement realm regarding the criminal justice system and how to improve on how we process people through the system to make sure they get the help they need. I'm going to turn this over to Beth now to give it to the Intervention and Treatment Recovery Part of the discussion. Thank you Dr. 15 minutes. Okay, thank you. Including questions? Let's go 10 minutes and then let's open it up for another 10 minutes of questions. So when we think about a common answer to the Intervention and Treatment system we're thinking about a classic pyramid where you try to have things that impact the biggest part of the population and most widely available and then focus the intensity of services as you move on off the pyramid and so things like hospital detoxification or residential treatment are at the top of the pyramid so you want to use them selectively and when indicated and things like prevention services and recovery supports are towards the bottom of the pyramid. You want them to be widely available to the population. One of the most important interventions that we can do is to more systematically identify across the population who may be at risk of risky substance use so that you have an opportunity to educate and support and perhaps divert from actually developing on into addiction. So for instance if you have a family history or personal use of some substances you might be more likely to be addicted if you were to strive additional like opioids and doing that might make a difference in how a provider interacts with you and what is offered to you at different points of care. So this screening, refiner mention, referral to treatment is a population-wide focus that's designed to help identify as we said, risky substance use, educate and provide support so that it doesn't proceed to addiction. I'm mentioning it because we're going to bring it up in terms of future development and access to home care. Specifically for the management of opioids, we have a very effective treatment we've all heard about it in some detail, medication-assisted treatment and what that really is is simply the use of certain medications in combination with counseling and behavioral health and other psychosocial supports. It's important to emphasize the combination there isn't just about the medication it has the typical medications that we talk about using are methadone, which can be only dispensed in highly specialized programs, programs that in Vermont we call hubs and then also medications like buprenorphine or vibratrol, which can be more widely prescribed by a host of MDs, nurse practitioners, physicians, assistants in any general medical setting. That combination of use of medications with the behavioral health counseling and psychosocial support strategies combined, whether it's buprenorphine, methadone or vibratrol, has been proven to be really effective in reducing opioid use for people who receive that service, increasing people's evasion and staying in treatment, which is incredibly important to recovery. It's associated with reduced morbidity and mortality. In other words, people who are in treatment are much less likely to die of overdose deaths. It improves social functioning. It's also medication assisted treatment is associated with reduced criminal activity and also reduction of the transmission of infectious diseases such as hep C. So in Vermont, what we did was essentially build enhancements into our existing methadone treatment programs. We arranged it so they had an additional nursing services, counseling services and consultant psychiatry. We had them begin to dispense all of the FDA approved medications for the management of opioid use disorder previously. We had only been using methadone. And perhaps most importantly, we endorsed caseload expansion to as many people as we needed the treatment as opposed to essentially treating the service like a waiver program with a capped number of people who were being served. When we began this work in 2012, our opioid treatment program for methadone was dispensed collectively served about 650 people. Currently now in 2017 they're serving close to 3,300 people. So it's a dramatic increase in access to treatment. We're currently operating five programs have nine sites across the state. The other thing that we asked these hubs to do was to be resources to the general network of outpatient providers who are offering medication assisted treatment in general medical settings. We referred these colloquially as our spokes and really what they are are any primary care office of any strike every qualified health center, small independent. Often outpatient substance abuse programs, pain clinics, OBGYN and psychiatry practices. These are where providers with mid-level or MD credentials are prescribing the morphine individual for the management opioid use addiction, opioid use disorder, and also who have additional staff that we put in place to support them specifically a registered nurse and a licensed mental health and alcohol addiction clinician. By putting the automated nursing and clinicians directly in the practices with the prescribers it made it possible to really link the assist along with the medication that are so critical to medication assisted treatment. We currently have a little over 64 full-time equivalent nurses and mental health addiction counselors working in 80 different practice settings across the state in Vermont. This is unique when we develop this. No one else was doing this combination of both enhancements both to the opioid treatment programs but also to the general medical centers and now other states are starting to replicate this type of approach. Let me just briefly say that this is a study conducted by our wonderful colleague Richard Lawson who has retired back to Vermont not really retired and engaged a really thorough and powerful qualitative study where he interviewed 80 people who were in treatment either in a heart or a spoke and then 20 people who were not in treatment but who clearly had an opioid use disorder. And for the folks who were in treatment he asked them think about how many days you were using opioids before you got into treatment and not think about the past month how much opioid use have you had. And so for those people who were in treatment their rates of reported opioid use or opioid ejection from the time before being in treatment to now being in treatment were dramatic and decreased. In other words people in treatment were not elicitly using opioids where the people who were still remained out of treatment were using elicit opioids at similar rates between the two time periods. The folks in treatment also reported to us that they had significantly reduced their number of emergency department visits, their overdoses their days participated increased their days participating in school or work had decreased the number of interactions with the legal system and they also report more stable emotional well-being. I can tell you that this is consistent with what we see in the claims data. We are tracking a group of people who are receiving medication assisted treatment in either hubs or spokes compared to beneficiaries who have opioid use disorder who are not getting medication assisted treatment and we see statistically significant lower rates of inpatient days and emergency department visits. We have published these findings. We are gradually and successfully eliminating weightless and dramatically increasing people access to treatment and the work that we did to augment the services in the hubs has been instrumental in this and also the creation of new programs in underserved areas so we introduced programs in Rutland and in St. Albans most recently and that's made a dramatic impact on being able to increase the number of people who are actually in treatment. We see a similar but less dramatic increase in what's happening in our spoke census although it's still a significant increase in enrollment and positions and providers and practitioners tell us that having the augmentation of the embedded nursing and counseling staff makes all the difference in being able to provide this service in a busy primary care practice. So things that we are working on going forward. We're engaged in a discussion with the Centers for Medicare and Medicaid Innovation Services and also with the commercial payers to help make what we're doing in terms of hub and spoke treatment something that becomes all payer. Currently Medicaid is the primary payer for these services and so this is an important policy threshold to have all payers recognize the importance of this epidemic and the significance of the service enhancements that we have been making. We are engaged in working hard to model what it would take to bring that population based intervention that I described screening, re-intervention, and referral to treatment to scale and all of Vermont's emergency departments and primary care practices. We have tremendous amount of working development that we are looking to do to help support the expansion of peer recovery supports. We have a very strong and impactful recovery center network but it is under resourced and undersized for the job that it really could be doing and should be doing and it's really on us to change that. And finally the other thing that I'd like to speak briefly about is the importance of providing a larger set of tools that we use in the management of pain. You'll remember from our earlier remarks related to how we got into this situation the use of opioids for the management of both acute and chronic pain is part of what has created so much exposure in the population. Now as we back off on our use of opioids and the science tells us more clearly what are the most effective treatments for pain and they do not necessarily include things like opioid prescribing but focus on things like physical recognition, cognitive behavioral therapies and approaches, essentially your physical fitness and your well-being have a tremendous impact on how we will do with pain. So as we use less opioids we need to develop better service models and better pain models to support the integration of alternative therapies and approaches in the management of pain. So Dr. Levine and I and a team of folks who are working across departments on this are working hard to get all payer participation across our hub and spoke initiative to develop and model a universal intervention and early intervention approach and screening brief intervention and treatment to create alternative approaches to management of chronic pain and finally to also greatly enhance and expand our access to peer support recovery services throughout the city. I'll be more clear. We're good. That was truly a very fast presentation of a ton of information done very efficiently. I just want to say that I'm proud to live in a state that as a college there's a problem rather than trying to hide it and try to seek solutions. I want to thank you both for your work and it was a lot of other people that you've done and so on and so on. A couple of stories harkened in my mind. One was from when he tells a story in the 70s where a group from Massachusetts wanted to buy a hotel here and set up an in a residency program. Basically they couldn't find enough addicts in the entire state of Vermont to even do it and then fast forward to where we are today. It's pretty scary and I remember being in the house as a lead sponsor of a bill that created the first drug court and it was actually Peg Flory who was in the house at the same time that actually carried the water and actually got it through. We thought we were in a crisis back then and that was over 15 years ago and here we are today. It's very depressing and yet uplifting to realize that you're confronting it and trying to move forward. Does the board have questions for Beth or Mark? I just have a comment actually. I just want to thank you again for having these remarks and also tell you that you both mentioned collaboration across the agencies to the extent that you know the remat and care board through our regulatory portfolio can be helpful in alleviating this crisis. Please let us know of opportunities that we might have because the data that you presented was pretty compelling and disturbing and it can be helpful. We have tried to provide a view of a comprehensive approach. We have rested on our laurels of how they spoke for a number of years now and we should. We should be proud of them justifying them and when you look at other states they are catching up but they are way behind in many cases. So what Beth outlined in her last sentence or two of a much more comprehensive approach I wouldn't say we haven't been doing a comprehensive approach but when you've got treatment kind of as a check mark we're doing that and they need to find out now because we have access to treatment and anyone who wants it can access it pretty readily. So now we have the luxury if you will of really expanding on the prevention and recovery science and really trying to make meaningful programming and meaningful interventions that are part and parcel of the overall health care. It should be included in what insurers consider comprehensive work in this arena so that they're not paying over and over again for the same person or for new people who should never have gotten to that point in the first place. So I think it's kind of a luxury that we can actually look in this very expansive way and very visionary and idealistic way if you will and say how can we really make our entire system better we will be looking to your option. Any other questions from the board? If not we're going to open it up to public questions or comments Dale. This might sound like a curve ball. I'm going to do my best to try to describe this. First of all I totally validate the crisis. I want to be clear on that. So there's a population of people who happen to be one above that brushes up against this policy but we aren't what this is describing. We happen to take either a controlled substance because we have epilepsy or some other medical condition and that's my own history, is epilepsy. Kevin you mentioned it. I can remember, I mean I didn't know what epilepsy was until like 1972 and in the hospital I've been diagnosed with it. Of course I'm not the ICU the first time. They put me on Phenogarbital. That's about as controlled as you can get as a substance and going back to my school and having kids wanting to buy it for me to get high and I'm trying to figure out why you want that kind of hell in your life. I don't think I just swore because that's what it was because within a month I'm in the ICU because the dosage since they didn't have BMI was so high, non-toxic. It took a very low amount for my body to get poisoned by it. I guess that's a simpler way to put it. I also had this ability to go into what they call Staniscentolectus which meant by the time you get to the dosage that would save my life. Now I'm in crisis because still of the dosage. Either way I'm going to die. There's only one way I'm going to live. There's more ways I could die than I could live. I walked into my doctor office just last month. I've got one controlled substance still in my life. It doesn't bother me. These things have kept me alive. They are medicine to me. He puts this form before me that says I'm supposed to keep it in a safe and I'm supposed to sign it. I simply looked at him and said, you buy the safe, I'll keep it in a safe. Otherwise I'm not putting this in a safe. I don't own one. That was really what I was saying. But he explained to me how this is a problem and that's why you have this. Because other people, and I see it now in the chart. I didn't know that. It's like it comes through relatives and so forth. I honestly had no idea what he was really talking about. Why he was giving me this policy. But I just thought it was over the top. What do you do with these people? I can't be the only one. I know I'm not the only one. What happens to that population? They squeeze right in the middle. Do you want to tackle that, Dr. McGean? They may not require a safe. But it doesn't require you to be safe in your approach to how you store medications. And knowing who is in your house or not in your house is a big deal. Are there people who do have bad habits in general in their lives in regard to addicted substances? Are there adolescents and young adults who may not have those bad habits but just the fact that it's available and they know where it is and their inquisitive could lead them down a path you never want to see them go down? So it's really the education about that and citing and informed consent that you understand that and you've been counseled about it as opposed to I agree to put it in a safe and no one else can get into it. For each household it will work differently. But it's really the process and the fact that you never had to have that conversation before with the doctor until all of these rules came down and that's a wonderful thing that we now have these conversations because it puts it on your radar screen whereas you may never have thought of the fact that the drugs you have in your house could be diverted in ways that you couldn't even have imagined before. I think it's really the education, the informed consent, the conversations and the critical part and you decide how you can navigate that and do the right thing in your house for the people around you. Sure. How do I validate though that I need that because they've got it so restrictive I feel like I'm going through chaos sometimes just to get to the medicine you can't pick it up until two days before what they call is the right time to pick it up and there is this thing about using it as needed because you may need to take it an extra one. You start to have an aura and it looks like you're going to have a seizure that is you take an extra one or you know you take your chances it's up to you. I don't particularly like it so what do you do with that? It's again the conversation and you and the physician understanding what are the circumstances that would make you utilize more in a given month than you theoretically needed to have and making allowances for that based on the fact that there's a trust built in between the clinician and you based on the experience you have with each other but I know it does seem like you're jumping through hoops sometimes and you're actually having to justify a behavior that you never would have thought you'd have to justify knowing your own condition but that's kind of the world we need to live in with the severity of the problem that we have with these kinds of prescription drugs. Think of it this way Dale you may be going through some inconvenience and a little bit of struggle you may be helping someone else to never get addicted to something so. And I can live with that. Good, thank you. Okay. Kevin. Yes first a quick disclosure I had mentioned to Beth Tansman today over lunch at the state house that I was hoping to meet the health commissioner not quite this way but that's the way things unfold I think he could stop you on the basketball court. Well, we're going to talk about that because I did hear that he might have Yukon on this background We'll talk about that but I directed the mental health association for 30 years and I think Beth and I interacted over maybe 20-25 years so we kind of we aren't that old and yes and you know I do want to say that I think the presentation is quite good particularly for somebody from Yukon I mean it's really having said that there's one shortcoming that I really want to take to task I think that in the presentation there's much too light and not educating the public about the role that the pharmaceutical industry played in creating this problem in 2009 I was very involved in a piece of legislation that passed that ban gifts from the pharmaceutical industry to Vermont doctors and I was around this time of year where several legislators came to me and said we should extend this ban to other regulators and other elected officials and I'm a very compromising, easy going guy so I decided not to do that because I wanted to pass the bill and if we had tried to do that in April it would have gone down I think. Having said that it was Purdue Pharmacy and several other pharmacies that created this problem they lied and misled physicians to a point that there's a major lawsuit and so I have a couple of questions I presume that Vermont is now part of that lawsuit against Purdue Pharmacy Pharmaceutical where the charge is that they absolutely misled physicians as to the potential side effects and addictive qualities of opiates so that's one question. The second question has to do with the health department it's great to have a new leader and it's great to have a spokesperson particularly one who is going to be standing up tall above others but it was very upsetting a year or two ago after the legislation passed I happened to notice the health department allowed a number of pharmaceutical companies to be participants and the health department functions. I think that's a bad policy and I ask you to take a look at it. It sends the wrong message from the point of view of an advocate and that could be argued. And the last part which has to do with not letting history repeat itself and this is what's troubling because unless we really educate the public as to how the pharmaceutical industry can distort frankly, part of our whole health care complex, look at the amount of money we're spending what you outlined today is millions and billions of dollars and it really partially stems from the behavior of the pharmaceutical industry and perhaps the weakness of doctors in not questioning more what they were observing. So creating a firewall between pharmaceutical industry and leaders in the state may help not have this repeat itself in 5, 10 or 15 years. So my last request or question is I hope that you will seek out people in the state below you and above you to find out if they are taking pharmaceutical money and perhaps you should start at the top because I can tell you that's an issue. I remember all the questions you raised. Those slides didn't get a sentence to the issue of pharmaceutical companies misrepresenting their drugs. You're absolutely right. Misrepresenting the addictive potential of the drugs in an almost reassuring way to clinicians saying that these are wonderful drugs, we have a revolution in management of pain and by the way not much harm associated with them. Your patients are not going to get addicted which was complete rubbish. So that needs to be stated. With regard to Vermont and the lawsuit we all want to see Vermont in that lawsuit that's an attorney general's office decision and they are completely invested in the process of figuring out but that I have not got word finally from them yet as to are we signed on or not. And it may be the difference between doing it independently as Vermont versus signing on with a number of other states that have already done it but they haven't taken their eye off the ball. I just can't give you an answer as to what their final decision is going to be about how we do that. Because I agree that it does need to be accountability in that quarter. I can't say much about Health Barbon prior to one year ago in terms of events that pharmaceutical representatives might have been at or what have you. I can certainly tell you that like any industry we get advocates knocking at our door wanting to meet with us and it's quite clear when they're meeting with us that we're not endorsing anything of theirs or whatever. We're just there to hear what they have to say. But in terms of a public event since I've been a health commissioner I can't recall any in the last year where they would have been front center in a setting that might have been inappropriate for that to occur. Again thank you very much. We've learned a lot. And if that can come down thank you. Robin can you confirm her on the phone? I must both. Great. All of us are sending you love and well wishes. Thank you. We'll do. You all have time to think as possible. I'm really just recapping some of this discussion from the last few weeks about the fiscal year 17 approaches. So I'll start by recapping the enforcement options and really the focus is on the middle three here. One option is to reduce UBMC's commercial rate by anywhere from one to three percent effective October 1st. Second option is to reduce CBMC's commercial rate by one percent also effective in October. And then the third option is to allow UBMC to self-restret to approximately 21 million of its actual overages to enhance and patient mental health treatment capacity in the state. And those are really the options of the board as before. So quickly the impact of the rate reduction if UBMC and CBMC engage in commercial rate reduction is usually the health network work estimates that for each one percent reduction for UBMC it would be valued at about seven million and the one percent CBMC rate reduction would be valued at about 900,000. And then the next two quotes are directly from Blue Cross Blue Shield from some information that Sarah gave us. And basically she said that based on their 17 calendar year charges for members of the cloth like health plan, large group and ASO lines of business, that each one percent reduction would be worth about $280,000 per month. And similarly a three percent reduction would take place on July 1st. And this is for UBMC would result in about a $5 million saving according to Blue Cross or if it was implemented on October 1st about $2.6 million. This really just encapsulates some information that Mike Deltrack gave us last week from VOD about what's happening in terms of mental health outpatient ER utilization. And I highlighted some of these numbers because what you can see is that for discharges, numbers of discharges, the same day discharges are actually falling as a proportion of total discharges, well the same time those folks were spending at least one day in the ER and in some cases more than 10 days that proportion is increasing pretty significantly over the past three years. You'll also see that the percent change in overall numbers of discharges isn't that great. It's a fairly stable sort of a modest increase. But what's really notable is the number of days. Again a really large increase from 15 to 16 in the number of days that people are spending in EVs and similarly 2016 to 2017. So it's really those that length of stay or the number of days that's driving the increase. And this just provides more detail that you can look at at your leisure. We heard from Commissioner Bailey on April 4th and we heard from Dr. Paratini from UVM as well at that meeting. And there really were some capacity issues that they pointed out. These are just the ones that I made there but there were many others. They said that in addition to people waiting in ERs for beds, others are also likely waiting in medical surgical units or at home and they particularly noted that kids may be waiting at home. The capacity issues are driven partly by increasing numbers of people needing services partly by increasing intensity for those people who need services and then also they talked about the inability sometimes to readily move people to the next level of care. Elected mental health admissions are rare. Most of them are emergencies I was pointing out. It was noted that CBMC in particular is close to six courts and so there's an increasing court order of cases at that institution. There was quite a bit of discussion on what's happening with federal funding for the Institutes of Mental Disease and I have been affiliated with hospitals. My understanding from their presentations of that will be phased out beginning in 2021. That could impact 25 adult beds at the Vermont Psychiatric Care Hospital and 89 adult beds and 30 children's beds as there were three. And then Commissioner Bailey noted that the state's been working on those issues since at least last year. So I'm going to restore my reading and that this is going to require a multifaceted solution. A key part of that is developing additional inpatient capacity. This is a synopsis of the UVM Health Network proposal that was outlined at the last meeting. So the proposal was to build additional beds and to build that at the CBMC campus. That then determined Dr. Paratini in a way that would require additional analysis. The second part of that proposal was that the Vermont Psychiatric Care Hospital could potentially be transformed into a secure residential facility. That speaks to some of the other levels of care where additional capacity may be needed. UVM Health Network indicated that they would continue work that they've been doing on other initiatives. Medication assisted treatment, which we just heard about. They're intensive outpatient care, partial hospitalization. They talked about charging crude additional child psychiatrists and then integrating primary care and mental health care. And some of the benefits that were outlined is that people could in fact get more time to care. There would be improved after care for when they were discharged from inpatient care from the ER, decreased burden and wait time in the ERs and then the resolution of the IMD issue. So additional benefits could occur. It's a little hard to predict these without a firmer proposal. But there are some benefits that could occur if capacity was enhanced and that might be a little more financial in nature. Some examples are that perhaps there could be reduced expenditures on observers. UVMMC noted in their 2017 actual narrative that they recently employed 120 observers at TEs and the average cost at millions 5.4 million. Clearly there could be reduced inpatient days if people were able to get to care sooner or could be reduced ER days as well. And if hospitals are thinking about expanding or reconfiguring ERs to deal with the mental health crisis, that could be a little bit of additional capacity as well. So I'll stop there and allow you to engage in discussions. Thank you, Pat. Before I open up the public discussion, does the board have any questions, Pat? If not, would anyone be able to push to offer a question or comment? So at this point we're going to open it up. We didn't receive any public comment either with public comment. Right. There was no response to the public comment period. So at this point we'll open up the discussion on a potential vote. Would somebody like to make a motion? I would. As many people know, I think I'm pretty optimistic about UVM's proposal and the opportunity that this brings to maybe alleviate the financial and clinical crisis that we see in the mental health system. So I'm going to propose some language here that I think allows UVM to self restrict that $21 million to invest it in patient bed capacity but add some language to ensure accountability. So here it goes. Pursuant to Green Mountain Care Board Rule 3.0, Section 3.4, in order to address the fiscal year 2017 actual budget performance at UVM Health Networks Vermont hospitals, the Green Mountain Care Board would provisionally allow UVMMC to self-restrict $21 million in surplus funds with the condition that such funds be used solely for investments that measurably increase in patient mental health capacity in Vermont. Beginning July 1, 2018 and quarterly thereafter UVM Health Networks shall report to the Green Mountain Care Board on details of its plan for making such investments including all progress on Green Mountain Care Board established milestones to date and must quantify how the plan will significantly increase access to and quality of mental health treatment and lower overall system costs. UVM Health Networks shall continue to report quarterly until such time as the Green Mountain Care Board determines that one the Health Network has made sufficient progress on its investment plan so that no further reporting is required or that reporting may occur at longer intervals. Or two that UVM Health Network has failed to make sufficient progress on its plan to substantially improve the patient bed capacity to alleviate the mental health crisis. If the Green Mountain Care Board determines insufficient progress has been made, it may order that UVM Medical Center use all or a portion of $21 million to benefit retailers through a commercial-rated production. Open that up for discussion. Is there a second? Not a second. So it's been seconded by Robin. Now we'll open it up to discussion. Tom? So I'm going to offer an alternative to that or a substitute to that motion. I think we're trying to get to the same place maybe in a different way and so I'd like to take a minute here just to kind of frame my proposal. I think that we have two crises here. One is a crisis of affordability and the other is a shortage of inpatient mental health beds. Those are both very evident. Regarding affordability, we have the REMD study sponsored by the legislature that concluded that low and middle income folks in Vermont pay more of a share of their income than those of our income. We have the health care advocates analysis, kind of three macro approaches to looking at affordability and the advocate concludes and I quote, all three models demonstrate that unaffordability is both unquantifiable and that health insurance plans offered by the Vermont Health Connect are unaffordable to many wide range of Vermonters. We have Divas analysis on affordability that shows folks at 400% of poverty in Vermont who just use an average amount of health care utilization are paying 80-18% of their incomes for health care and people are high utilization, they're paying 15-30% in high utilization years, inclusive of subsidies. We also have the Divas analysis of migration plan that folks move from one type of plan to another from 2017 to 2018 showing Vermonters moving to bronze plans and lower actual value silver plans thus confirming the above pressures regarding inpatient best, I wasn't here then but I understand it's been a healthy discussion back in 2017 on this issue. Unlike Pat presented I respect and understand the information that the Vermont Association of Hospitals and Health Services presented we have a problem that's growing. I personally witnessed this last week when I visited Northwestern Hospital and I see an armed guard outside a cubicle or a room in the emergency room so it is a real issue. In terms of the recent process in this regard the administration and former chair here made a proposal to the legislature that legislature has not gone very far on that so far and the houses voted yes to replace the middle sex beds that were created in response to Irene and as under significant pressure to do that because FEMA is threatening to claw back the money that was used to build those beds the houses rejected the administration's proposal to build 12 temporary beds at the Northwest Correctional Facility and they've taken no action on any long term solution to this problem such as the one that Jess suggests the Senate has yet to act so we're in a situation where nothing is shovel ready even if approved today. There is no site plan. There are no environmental permits. There are no traffic studies. There are no certificate of need applications. There are no architectural drawings and any cost sharing agreement with the state has not been developed I mean we're here today I think because of some serendipity on March 14th the presentation from staff was totally in the arena of using these funds these over funds to reduce the rates of the hospital and that flows back hopefully to rate payers the staff recommendation was at 20 million for course grade reduction up to 3% from the UVM Medical Center budget overage and again as Pat's presentation profiles each 1% was worth $280,000 per month. At that March 14th meeting Jess raised the issue to her credit of the need to address this crisis and UVM expresses interest in building beds at Central Vermont though it is just a concept. There are no specific plans when asked what would be the number of beds we were informed that it was somewhere more than four or five and asked for a range well maybe it's around 30 so we are at a very preliminary point and substantial capacity is three to four years down the road in terms of the process to get through the design, the funding, the certificate etc. and I don't think that the bulge from 2017 and past year should be kind of held in advance held away from great payers when it can have or at least some of it can have some practical use in the immediate future to provide substantial reductions to the cost of health care for many designers to provide so the motion I'm going to make will be to provide substantial state background for mental health beds from the 2017 to any 2018 overages and get this project on a responsible track so that it is done well so I can this to be copies of my motion to my follow-up. I think it would be helpful if you read it. So I would like to substitute the following relative to UBM Medical Center's 2017 budget net operating income bulge of 20.64 million that 14 million be used to reduce UBM's medical center's commercial rates by 2% or 14 million whichever is greater. Effective October 1st 2018 and that 6.64 million be held in a designated reserve by the UBM Medical Center for the purpose of the planning, design, and construction of new inpatient mental health capacity at Central Vermont Medical Center inclusive of any cost-sharing agreements with the state and any marginal effects on the all-payer model targets. By December 31st 2018 UBM Medical Center may expand up to 10% of said 6.64 million designated reserve for the purpose of developing a certificate of need application for such new inpatient mental health capacity. The balance of the reserve shall be authorized for expenditure pursuant to any Green Mountain Care Board approval of the certificate of need for such new inpatient mental health capacity. Further it is the intent subject to further approval of the Green Mountain Care Board that any 2018 budget net operating bulge of the UBM Medical Center be allocated 67% to the designated reserve for new inpatient mental health capacity at Central Vermont Medical Center and 33% for commercial rate. I think if there was a shovel ready project today this approach wouldn't make sense. We'd be ready to go and we'd need the money but we're three or four years down the line and we also have a problem out there that we can address now. So this proposal allows us to send money back to great payers which is a good thing. It puts a substantial financial stake in the ground for UBM Medical Center for a facility at Central Vermont. It provides two years worth of investment in a reserve for that purpose, the 2017 overage and the 2018 overage. And it gets this project into the budget cycle for 2019 and 2014-20 and leaves opportunity as well for UBM Medical Center to negotiate with the state for some cost sharing if possible from the state. But at this point it's clear there is nothing at the state level. There's nothing at the legislature to move the development of these debts forward and I think an immediate investment of over six million dollars in the planning and buying makes sense. And then the 2018 overage is not a given yet. The 2017 overage is fact, the money is available. In 2018 though, because we benchmarked UBM Medical Center's budget based off its 2017 interest and they are through 2018 apparently running a little lot relative to their budget, there's likelihood that there will be a lot more money in 2017-2018 and this proposal takes two thirds of that and preserves it for the UBM Medical Center to basically construct these debts. So I think that this is a proposal that strikes at the two stars that you had on your first slide, which I didn't get to put that in my packet, but there wasn't anything there that I didn't know. But this is kind of a proposal to help repair and get UBM Medical Center on the road with a facility at Central Vermont and gets them in a position to have itself shovel ready three or four years down the road with funding to construct it. Thank you, Tom. Is there a second? You're still on the phone, right Robin? I don't have a second. I just want to say that I think that where we are today is far from where any of us were a month ago in that either one of the two alternative motions actually recognizes that there could be possibly a greater return to Vermonters by investing in trying to alleviate the bottlenecks in our emergency rooms there, causing hospitals to use expensive sitters, expensive security, and even more importantly than that that are denying patients the right to timely services. We would never tolerate someone sitting in an emergency room for days waiting for a cast to be put on a broken leg or what have you and yet the state has tolerated this for too long. So although there wasn't a second to your motion, Tom, I think that there's still the opportunity to get to what you're talking about if there's another hot year and at least this gives the opportunity to allow UVM network to move forward under the proposal that Jess has made and that Robin has seconded to try to work on the plan that actually achieves the core goal of reducing those wait times, creating better care for patients, and actually saving Vermonters money. So with that I think that the fact that we have all come to that same recognition when just a few short weeks ago prior to Jess making the motion, I would say that the only thing that was considered was a commercial rate cut. So I think we've come a long way and that speaks volumes to the crisis that we have in our mental health system in the state. Is there any further discussion? I appreciate the chairs commentary but I think given that we are at the very beginning of a facility at Central Vermont and it is going to take a while to do it, that's a very complicated site I live in Berlin that we can do both. We can help rate payers substantially and we can put UVM medical center on the path to build a facility of substantial size at Central Vermont. I just want to add to the motion that Jess put forward one of the things we really need to work on is the definition of sufficient progress and how we'll measure that and I think that's something we should focus on with work with UVM on what the expectations are going to be to give a plan for that usage of the 21 million. I obviously don't expect in July that it will have a flesh out plan for that but I mean certainly in the course of this year by whether it's going to be the second quarter or the third quarter of the September or the December, really having a plan because to the extent that the motion had the option to potentially put that money back towards rate to rate payers and rate decline, I think we really want to make sure we have something we understand when it's going to go into play when that money is going to be needed and also to something that Tom brought up the expectation is that there probably will be some over in 2018, in your 2018 year, I mean we did talk about replacing your budget $39 million on the top line what we have an address is along with that, there should be some increase in operating profit as well and the expectation would be that whether that's going to go into this mental health option or into another option, it will be looking to track that as well during the course of the year. I just want to say I agree that this is just a concept at this point a lot has happened over three weeks and to be fair it is short on details, yes, but I think it's long on vision and far reaching and potential impact and I would like to give EDM the time and space and the opportunity to work with the Agency of Human Services to come up with a concrete plan how we can alleviate this crisis and I think that we can work with staff and staff can work with AHS and EDM and the Office of Milestones which we really measure the progress on this plan and I think I understand that Pat has already been thinking about Milestones if this was to pass and Tom I understand your point about this is three to four years down the line, the reality is it's three to four years down the line whenever we start and I think given the crisis that we have now we need to start now. Just to be clear the timing of the start, we're both together because the six minutes, seven million dollars is the start. I don't think it's enough of an impact. Well, there we disagree the planning process has to start somewhere and putting six million dollars from the get-go today into that and then building on that through the 2018 process and then the 2019 budget process we will probably get to the same place down the road at the same time except taxpayers will have to use at least 14 million of that 20 million and we'll get to where we want to go. Robin, do you have anything to add? No, I'm going to be unfair personally by it today. Understandable. Is there further discussion? If not I'm going to ask the clerk to call the roll. My clerk? I'm also an ambassador for wellness. I will start Maureen. Yes. Tom? Yes. Robin? Yes. Sharon Mullen? Yes. Passed with one descending vote from member of Pellum. Thank you. I think we do have to clear up another item in that at previous board meeting there was a provisional vote and I think that has to be decided one way or the other. Does anyone have a motion on the CBMC? Yeah, I'll make a motion there. I think that we had a provisional rate cut of 1% for CBMC but since I believe that the 21 million dollars is inclusive of at least some of CBMC's overage I would move that we rescind that rate cut. Is there a second to that motion? Is there discussion on the motion? The discussion I would have would be, it's not quite all of the total. I mean if it was 20.6 million that was from UDM alone so that we rounded out I guess 21 million and it was 900,000 for CBMC whether we look at 22.5 million or keep the 1% in there just want to discuss what options anyone wants to look at there. So is there other discussion on the motion? Rob, would you have anything to add on this? Okay. The clerk will call the roll. Member Hallam. Yes. Maureen. Member Ucifer. I don't know. Ucifer. Ucifer. Yes. Pellum? Yes. Mullen? Yes. Lunch. Yes. Okay. Is there other enforcement action come before the board? If not, we'll consider the 2017 enforcement close at this point. Pat, am I missing something? I don't believe that. Okay. Thank you Pat. I know this is a bit of a trial like fire but you've been thrown into your new role. There's been a lot that's been happening and we really, really appreciate everything that you're doing. Is there any old business to come before the board? Is there any new business to come before the board? Is there a motion to adjourn? Pellum. It's been moved and seconded to adjourn. Maureen. Clerk. Call the roll. Yes. Lucifer. Yes. Mullen. Yes. Hallam. Yes. Hallam. Hallam. Thank you everyone. I know it's been a tough day and thank you very much.