 Today, we have a potential new entrance to the ACO market here in Vermont. It's incredibly important that Vermont attracts interest from providers and ACOs, and we're excited to hear from Gather Healthcare today. That being said, we have a rigorous and important review process, and that is what we will go through today. I'll note for the record that there's no executive director report this morning. That'll be provided on Wednesday at our board meeting at 1 p.m. First, I'd like to go to the meeting minutes of October 12, 2022. Is there a motion to approve the minutes from October 12, 2022? So moved. And is there a second? I'll second. Great. Thank you. Is there any board discussion? Hearing none, those in favor of approval of the minutes of October 12, 2022, please say aye. Aye. Aye. The vote was unanimous. I'm sorry. Is there any nays? All right. Hearing none, the vote was unanimous, and the minutes are approved. Prior to turning to the folks from Gather, I'd like to pass it over to Marissa Melamed, who is going to provide an overview of our ACO review process. Marissa. Thank you. Good morning to your foster and members of the board and Gather Health. My name is Marissa Melamed. I'm associate director of health systems policy for the green mountain care board. And I direct the ACO oversight process. I have with me this morning to give you an introduction. Russ McCracken, staff attorney and Julia Bowles. Julia is going to kick off with a few introductory slides. And some background before we turn it over to the gather folks and go ahead, Julia. Right. And can someone just nod their head to confirm that you can see the slides? Great. Thank you. So we just have a couple of introductory slides as Marissa said, this one should look familiar to the board, but with some highlights to orient us about what we're focusing on today. So gather health, the ACO we're hearing from today is a Medicare only ACO, meaning that we're looking at the right hand side of this flow chart. And because they're Medicare only, they're not subject to the certification process and are only going through the budget review highlighted. I can on the right. And underneath that, because gather health has fewer than 10,000 attributed lives in Vermont, the review is based on standards and processes, the GMCB deans appropriate, whereas larger ACOs would be subject to all standards established under rule five. And finally, as highlighted in the bottom green box, the GMCB has developed Medicare only guidance earlier this year for ACOs with fewer than 10,000 lives. And that is the guidance that is the basis for today's review. So I will hand it to Russ to kind of get us into the details further. Great. Thanks, Julia. And I am going to keep this quick because I don't expect the board will be, you know, discussing this will be really held for another day for deliberation. But to frame the hearing and the question today, I think it's important to remember what the board's approving here for a Medicare only ACO like gather health certification is not required by statute. All that is required is for the GMCB to review and approve or modify the ACO's budget. And as Julia just sketched out, gather falls into the category of ACOs with fewer than 10,000 attributed lives in Vermont. So that gives the board a little bit of flexibility in determining which statutory criteria are applicable or appropriate to review and connection with gather health. Also note that gather health has an ACO operating in Vermont is subject to other reporting obligations that are captured under rule 5501. So next slide please. So for the budget review process, there are I think 16 different criteria listed in statute. What we've done here is pulled out eight of them that we think would be appropriate for an ACO that is participating in Medicare only. And with a smaller size, like what gather has these criteria may look familiar to some members of the board because they're the criteria that were used. The last time the board reviewed the budget for a Medicare only ACO. So I'll run through them. The criteria that you don't see here that are in statute. The general rationale that we followed is those other criteria that we haven't listed. They really apply to an ACO that has more of a statewide scope or a larger presence in Vermont. They talk more about systemic investments. They talk more about aligning statewide with different statewide needs. So what we have highlighted here are any benchmarks. Sorry. Not quite on the slide. Any benchmarks under 5402. Yeah, no, I'm sorry, Julia. You're right. Next slide. So here are the criteria is information regarding utilization of health care services. By providers participating in the ACO. I want to think about character competence, physical responsibility and soundness of the ACO and its principles. Any reports that are available from professional review organizations related to the ACO. The any efforts the ACO is making to prevent duplication of high quality service. The services are being provided efficiently and effectively to the extent possible utilizing existing providers. And next slide. Public comment is an important part of the board's regulatory process and so that will be an opportunity today for that and the board welcomes and appreciates public comment. And the board will also consider the information gathered from this meeting and any other staff meetings that we've had with the ACO. Information on the ACO is administrative cost, the extent to which the ACO makes its cost transparent and easy to understand. And the extent to which ACO provides resources to primary care practices to ensure that care coordination and community service, including mental health and substance use disorder counseling. Can be provided without unreasonable burdens on primary care. To the extent that that is applicable to gathers healthcare model. And I will then turn it back to Julia to go through. So the broad timeline and the couple notes on the agenda for today. Great. Yeah, thank you. So this slide just has a quick reminder of the timeline for this overall process. Today, of course, we are having the budget hearing for gather health. Next week on Wednesday, November 2nd, the GMCB staff will be presenting our analysis of gather health FY 23 budget to the board, including our recommendations. And finally, there's a potential vote scheduled for November 16th. And as Russ just covered briefly, we wanted to reiterate the importance of public comment. You can get public comment later today in this meeting, but also we always welcome it online via our website. There's a couple key deadlines that we've outlined here just to help make sure that the staff and the board have time to consider the comments. So we ask that public comment be submitted by Friday, October 28 in order to be considered ahead of the staff analysis presentation, or Friday, November 11 to be considered ahead of the potential vote. And finally, we wanted to just show the agenda for today. So Marissa, Russ and I have just gone over the GMCB authority and criteria, as well as the timeline in public comment. Next, we will hear from gather health. Then there will be board questions, questions from the healthcare advocate, public comment and an executive session if needed. So as a reminder, parts of gather submission are marked confidential. So discussion of confidential information should be held for a potential executive session with the board, the buyers. And with that, I'm happy to pass it back to you chair foster or we can go right to Russ to swear in the witnesses and start the presentation. Yeah, please, please. Great. Thank you. For a gather house. I believe it's Mark and Mark who are presenting today. Is that right? Anybody else joining you? We also have good. Good morning, everyone. I'm a free soccer rest. We also have Andrew to on with us. He is advising us from a legal counsel perspective. Okay, that's great. I don't need to swear him in as, as attorney. So it would just be you Mark and Mark, if you don't mind. You would raise your right hand and do you solemnly swear or affirm that the evidence you shall give relative to the cause now under consideration shall be the whole truth and nothing but the truth. I do. I do. Great. Thanks very much. And I will then turn it directly over to you. You share your slides and. Start the presentation. Great. Thank you all very much. So again, I'm Mark breeze soccer. Good morning. Thank you very much for having us join you today to present. Our Medicare shared savings accountable care organization where we are gather health. We are a new entrant ACO and we're really, we're really excited about what we are endeavoring to do. And we're very excited about our about our partnership with with North Star Health, a federally qualified health center in the state of Vermont. Mark breeze soccer. I'm a general pediatrician. I grew up in the Midwest trained out in Salt Lake City, Utah at the University of Utah and ended up staying in Utah and practice general pediatrics for 15 years for a large integrated health system located in that state. I held a series of leadership positions, physician leadership positions during that time and served served on the board of that health systems wholly owned insurance company for about 14 years. And I, you know, over the 26 years I worked for that health system and insurance company. I had the opportunity to see a lot of different things in terms of innovations in health care. My main interest as a primary care physician was always around the the advancement of creating an environment where people can get the best care possible that they can really realize. To the fullest, fullest extent, their health, their well being and how could we as physicians and providers and clinical teams and and also as a health system or insurance company do our very best to serve them. I joined gather health this years we formed this the company and we embarked upon this journey to be an ACO and we're really looking forward to sharing more about that ACO this morning. I want to hand things over to Mark Attala mark for for your introduction and then and then we'll jump into the into the presentation. So, Mark, over to you. Thanks so much, Mark. And can everyone see my screen. Perfect. Mark, I assume you see yourself. It's a pleasure to be here and thanks for having us that your foster the board and all the Green Mountain care board staff that have been great to work with so far. My name is market Tom a pharmacist I most recently was a senior advisor to the CMS administrator for all of drug pricing and innovation. Prior to that I was at the CMS innovation center and I led our Medicare advantage and part d work as well as working through financials of the next generation ACO program. And so I'm hopefully familiar with a bit of these programs. Today, in terms of agenda we wanted to touch quickly on the shared savings program, a little bit of history. The statutes and regulations that were held to as far as part of being an SSP ACO really how the quality performance is set, and then how that ties into the ACO's finances and savings and losses. And so I did it over to the mark for the ACO background and care model, and then also budget financial model discussions and happy to hand it back to the board for questions that does that work for everyone. Any, any differences of order. Okay. I apologize. Okay, I'm sorry. I apologize for being monotone and any dryness of this presentation it's hard to really amp up the shared savings program, but I'll do, I'll do my best so in the affordable care act. There was a desire to say we have a lot of patients that are fee for service and beneficiaries that are entitled to Medicare they're entitled to Medicare for the rest of their, their lives. We think we can do better to manage those patients. And so, part of the patient protection and affordable care act was the statutory creation of the Medicare shared savings program, which will cite shortly. This has been the evolution of that program. So, you know, really started off as expected, smaller. It's now about 11 million beneficiaries. And so when we look at the combination of the affordable care act also created the innovation center CMS innovation center. They also run value based total cost of care ACO models. I think the one that you probably been most familiar with is direct contracting which has been rebranded the ACO reach model. The combination of the SSP plus ACO reach covers about 11.4 million beneficiaries, which leaves about, you know, 25 million or so beneficiaries that are not in a value based care model. And then I would think about the other set of patients that are in Medicare advantage or pace or another cost base plan and so that that's the entirety of Medicare today. And so as we think about the shared savings program, it's the largest of really any program CMS is running. There's a 483 ACOs and SSP this year. And as you can see, it's been successful relative to previous years in terms of generating true savings for the system, then also ensuring quality is met. So that's how the programs evolved over time. Just to hit on a few key points of the program. Again, Congress enacted the program to really say we need someone to be accountable for a patient population to really coordinate care, build infrastructure and redesign care processes to ensure beneficiaries receive high quality and efficient care. And so to start moving to the regs, everything's founded 42 code of federal regulations. This is section 425. Essentially, ACO is a legal entity establishes contractual arrangements with providers. And then as part of those providers, seeing Medicare fee for service beneficiaries, they're assigned to the ACO either through a claims based process, which is the majority of assignment. And then there's also a voluntary alignment option to ensure that a benchmark is mathematically or statistically valid. The ACO SSP program needs at least 5,000 beneficiaries. And then to ensure that the ACO really is run by the providers that these patients have chosen to see, the governing body of the ACO must be comprised really of that set of providers. And so at least 75% of the voting shares of the ACO's governing body is held by the providers that comprise the ACO and then also that Medicare beneficiary. The ACO's leadership certainly is part of the governing body, but may or may not have voting share. Further, there's a compliance officer for the ACO. In this case, it's me who reports directly to the governing body. There's also in terms of leadership management and ACO executive director, Dr. Breesocker, a senior medical director, and then someone that really handles quality assurance and then compliance. It's a five year agreement with CMS. And then as far as insurance or as far as a financial guarantee, because there's not a change to the person's insurance, so the beneficiary still maintains 100% of their Medicare benefit. They're entitled to that. There's no change there. All finances still go between CMS and the provider. So the provider will build CMS. CMS will pay that provider 100% of whatever the CMS rate is for that provider and for that claim. And then, and that's not changing. What really changes is at the end of the year, which we'll get into at the end, there's really a spreadsheet calculation to say, here's what CMS believes we should have paid for this set of patients for beneficiary. Here's what we did pay, how are the quality metrics had, and if there's savings after that, CMS shares those savings. If there are losses, the ACO is responsible for paying back CMS what the delta is between expected costs for that population quality assurances and then what actually was performed. And I'll pause that. I can pause either at each slide or feel free to interject whenever the board has questions. As part of this, again, because Medicare is an entitlement and a benefit, really there needs to be, from CMS's perspective and also ours, transparency and public reporting, marketing needs to be clear and regulated. There need to be a strong set of beneficiary protections and then the ACO must maintain audit records to be audited. And so in order to operate as an ACO in the shared savings program at least, beneficiaries have to be aware through signing the provider's offices, written notices that this participant or this provider is part of the SSP, the beneficiary may have to have data sharing. If they choose, the ACO maintains a public website, that website maintains information that CMS outlines. The ACO must have all marketing that the ACO creates to ensure beneficiaries are aware of the extra benefits or ways that the ACO can help the beneficiary. You know, it's filed with CMS and CMS has, you know, ultimate approval authority to ensure that nothing's confusing to a beneficiary or may negatively impact the beneficiary's use of their Medicare benefit. Again, CMS, HHS, and OIG as well as other federal regulatory agencies can always audit, inspect, investigate, evaluate the ACO or the ACO participants' operation of the ACO really at any time. And then, you know, to ensure an ACO is compliant, ACOs are required to have a compliance policy and then also a plan. And those plans really are, you know, to ensure that the compliance of officer or official is not the attorney for the ACO and then really has, there's a robust compliance process in place to ensure, you know, everyone's aware of what's required and if something is amiss, that there's a process to report that. In terms of care model and then payment rule waivers, and this maybe addresses a few of the questions the board staff have asked. So first, the ACO really is designed and fully insented to ensure that evidence-based medicines practice. And that patients are engaged, that there's shared decision making in terms of choices of care and decisions on care, that care transitions are implemented and we'll talk more about that later in the presentation. There's also, you know, an assessment of, you know, what beneficiaries' level of care and experience of care was, and that's part of this. ACOs are allowed to provide beneficiary incentives as one lever to ensure that if an ACO believes there's an option for better care, if something is not covered by Medicare, the ACO can pay for that. So that's dollars that are not provided by CMS, that's the ACO's investment in those beneficiaries' care. As long as the incentives are preventive care or do advance the clinical rule for that beneficiary and are connected to that person's care. There's the option for, so in terms of payment rule waivers of what is Medicare waived for ACOs that are part of the shared savings program. If you apply, and so these are really optional waivers, the ACO can apply to waive the rule that says before a SNF stay, you're required to have a three-day inpatient stay in the hospital. That's the one option. There's a set of requirements around that. We did not opt for this waiver this year. There's also a telehealth waiver essentially to allow the home as an originating site, given the use of telehealth during the public health emergency. This is already part of care, and so we didn't, it's a little bit of overcome by events, so we didn't have a need to apply for that waiver either. In terms of how all of this then plays into the financial performance, the ACOs are held to two things, either a set of quality measures that are deemed by CMS terms of web interface measures, or really there's three what's called electronic quality measures or MIPS quality measures, and then secondly a survey of patient experiences that's what the CAHPS indicates. And so that's the set of how did this ACO perform per CMS. And so in order to qualify for shared savings, the ACO must meet that standard on those two things. And then based on how the ACO performs in those two things, in the event that the ACO has losses, this really the performance on your quality performance indicates what level of losses the ACO pays back to the program, and which should make sense. The ACO that isn't doing low on quality, if they have losses, they pay back the most that CMS lists in terms of downside risk. So then the question is how much risk, and again this is really spreadsheet risk, does an ACO hold? So first there's a question of what level of minimum savings or minimum loss rate the ACO chooses and so the ACO can choose in the event of the enhanced track they can choose anywhere from zero to 2% of the MSR and MLR, which means essentially for the first 2%, let's say I choose 2%, for the first 2% of saving their losses, no money is changing hands. And so ACO ends up in 1.5% losses, they wouldn't pay anything because they're within their rate. There are some tracks that you can see here that have upside risk only. Those ACOs are then forced into a higher levels of risk over time. The enhanced track, which is what we are, is on the far right, and has a great set of financial incentives to ensure that the ACO is trying to impact positive care for beneficiaries. Again, I think it's important to note the relationship between a CMS and providers stays the exact same. The only positive, the only change here is that frankly is only positive for beneficiaries. There's a incentive clearly from everything we just outlined to ensure that beneficiaries stay healthier and are healthier and incentivize really high quality care management, which is what we can talk through next. Mark, I can hand it to you if that works. That's great. Before I proceed, thank you, Mark. Before I proceed, does the Board have any questions about the Medicare share savings program and the background that Mark Etola provided? Okay, great. Thank you so much. So a little bit about our ACO background. So 2023 will be our first performance year. As Mark mentioned, we are in the enhanced track. Our main intervention with our ACO is addressing chronic disease through lifestyle medicine. And we spent the spring and summer talking to groups and providers across the country who have an interest in lifestyle medicine and sharing with them our ideas around forming this ACO. And from those conversations, we entered into contracts with providers from the six states that you see listed there. Mark Etola has talked about the assignment methodology and the waivers being used. We have formed a board. 80% of those of the board are ACO participants. So these are providers in the different groups across the country that primary care providers who are and some medical specialists that are part of our ACO that will serve on our board and that the leadership team is accountable to for execution of our program under interventions, quality reporting, the services we're providing to Medicare beneficiaries across the six states that we serve. We also have two consumer advocates and when we receive our list of attributed people on Medicare to our ACO in December, we'll then be working to add a Medicare beneficiary who is served by the ACO to our board membership, governing body membership. We've elected a minimum savings or loss rate of 0.5%. So in that 0 to 2% range in the enhanced track, which is the highest, highest upside and downside risk model in the ACO, we've chosen that 0.5% as the minimum savings. So what is our care model? Our care model starts with the fact that as a population overall across the United States, we have been on a trend of rising chronic diseases. And there have been many programs in at state levels, at health systems levels, at academic medical centers in private practice, people really leaning into providing the best care possible across these many years, and yet we continue to see increases in chronic diseases. So our belief in our main intervention is number one, we want to keep doing all those programs that are working. So the programs that a particular clinic has, a program that a hospital system in a given region or state has, we should definitely keep doing all those things, the things that are adding value. We also want to intervene at the root causes of chronic disease. You know, it's amongst Medicare beneficiaries, 25% of everyone on Medicare today has type 2 diabetes. Another 4% have type 2 diabetes, but they've not been diagnosed yet. And another 50% have pre-diabetes. So we aim to begin to address this and addressing it by creating a community and bringing that community together across our ACO so that the people that we serve have information, they have a connection to each other. They have the ability to ask questions and support each other and try even the smallest things and work on the smallest things to improve their health and address either their risk factors for chronic disease or better manage the chronic diseases that they have. We also know that people when they do get sick need a lot of support. And so we aim to create additional awareness for our provider groups across the country about where their patients are. So who's been seen in the emergency department recently, who's been admitted to the hospital, who's being discharged to a skilled nursing facility. And so when we provide that information and that awareness of where are their patients getting care from, they are then able to apply care management interventions, transition of care support to make sure that those patients receive the best care possible as they recover from their illness. We will be also tracking on those that have multiple chronic conditions and high needs that also must happen with great partnership with our local providers. We kind of a key guiding principle that we talk about is that it really, it's the people that are closest to the patient care that knows their population the best. And so what we want to do is provide the information and resources to them with choice so that both patients that we serve as well as the clinical teams that are part of the ACO can take the additional resource that the ACO provides in terms of information and financial support. To intervene in the best way possible for that individual patient or for that group of patients being served in the community. And lastly, we really believe that it's important to know that people have services when they're very sick and that it's very important to know what each person's wishes are as they manage through an illness. And so we will be focusing on services around palliative care, hospice care, and other related things as people are managing the full scope and process of their lives and the medical care that they're receiving as part of that. So if you go to the next slide. This is a summary of our budget and financial model. I'll quickly walk through this and hit the highlights. The first, the first three rows really just gives you gives a total scope of the Medicare funds that are going to be flowing through the ACO as it relates to the 5000. Traditional Medicare fee for service beneficiaries that we expect will be attributed from through North Star Health and the providers at those federally qualified health center clinics. The benchmark that is estimated at this point, we will receive a final benchmark in December. You can see there is $9,900 per beneficiaries. That's how you get to the total project amount of Medicare billing and our total benchmark for this group of patients. We then consider and project, you know, a different three different models of shared savings one at 3% of savings that we generate a second level at 5% and then 7% is the third level. Just for awareness, the average amount of shared savings and in Medicare Shades Medicare Shared Savings Program ACO is 3.5%. So that means that of the total amount that $49,500,000. First of all, assuming a 5% shared savings, the vast majority of that 95% the 47 million plus continues to flow to hospitals and clinics and and providers in Vermont that that are serving patients today. Then importantly of the of the 5% net shared savings that the 2,475,000. Over 80% of that will go back to Vermont beneficiaries, Vermont providers in the form of in kind incentives, care management support and and additional shared savings with Vermont providers. We estimate operating expenses of just shy of a quarter of a million so 225,000 leaving net shared savings retained by the ACO of $255,000. And there's some percentages at the very end there that shows just overall of all the dollars flowing through the programs where what percent stays with Vermont beneficiaries and providers and the percent of the total that is expenses for us and the percent that's a total of shared savings retained by us. One quick correction for the record so we'll receive a final benchmark actually and expected a second half or July of 2024 for the for the actual the actual year so that helps. Yeah, thank you so yeah so we we have an estimated benchmark that will be aiming for but the but the final actual benchmark that that is that is what we'll receive from Medicare. Once there's been all the run out of claims and all things have been reconciled after the performance year during 2023 so that final benchmark is then 2024. Thank you. Thank you, Mark. So, we've had a chance to review information about Medicare Shave Shaving Program overall. We've shared our model of care and that we're focused on lifestyle medicine as a key intervention, and then shared our financial plan. So, thank you again for this time and we are looking forward to your questions and the discussion and we'll hand it back to to the staff to facilitate that. Thank you, Mr. Breeshiker and Mr. Attala. At this time, I'll note I have a few questions myself. Some that pertain to information gathers designated as confidential and others that are not. But I'll turn it over to my fellow board members for any questions or comments. Thank you. I'll go ahead and start if that works for you, Mr. Chair. Please. Great. Hi, I'm Robin Lunge. I've been on the board for six years now. So nice to meet you all. So I have a few questions and I thought I'd start with follow up on the care model. In your discussion of the care model, you talk about creating a community. Are you expecting that the community is a virtual community, an in-person community, some of each? Could you just give us a little more information about that? Yes. Thank you, Robin. It's nice to meet you. So the answer is yes to both. So of course, people will continue to have their in-person community. So family and friends and those around them that are, which is so important when receiving medical care. Additionally, we will create a virtual community, a community of people that can connect with each other with questions. They can share their experiences. It really is based on this idea that your community overall is your caregiver. Now, sometimes as a physician, I'm like, wait a second, I'm the primary care doctor. And that's true. But the reality is that I'm one part of a community. And I think that's something, especially as a pediatrician, where there was always a whole bunch of people in the room. In fact, from my perspective, the more people in the room together, I loved it when grandma and grandpa came to visits and would ask questions. And it just reinforces that it really takes everyone around you to care for someone, whether that's in raising a child or caring for a friend or a family loved one. So providers are part of that community and we have our expertise. But I think that's someone who has type 2 diabetes and high blood pressure and has been living with that and actually doing a really great job. They have that practical and pragmatic expertise and that's what needs to be shared. And the interesting thing about lifestyle medicine interventions is that it starts with just one small step. Just a person saying, I'm going to try something pretty straightforward that I've seen others be able to do and they've shared some of the ways that they made that happen. And that information, that idea, that idea can spread through a community and before you know it, it's just who we are and what we do and those are our traditions. And so that's the model that we want to leverage. And maybe one other point I would make is that this is a model where it's super important to have great partnerships with providers. But we're not as dependent on the provider care. We want them to do their thing, keep doing that. But this community can sit right next to that, to the clinics and the hospitals and the care that's being provided and be additional and additive to that care that's taking place. Thank you. One of the other questions I've had was related to the in kind incentives. Is there sort of a standard suite of in kind incentives that you anticipate offering your providers in multiple states? Or is that something that you leave to the individual provider office? Could you just speak a little bit more to how that will be designed and give us some examples of what in kind incentives might be? Sure. So in the regulations, the in kind incentives are focused on those that we provide to the Medicare beneficiaries. So it is, it really is, it's anything that can help them manage a health condition or prevent something from happening. So from a lifestyle medicine perspective, what we want to do is provide flexibility to them so that they would be in a position to elect to maybe it's purchase groceries that are healthier. They might need help with transportation expenses. And so what we want to do, I think the important thing within our model is that we align those incentives with the activities that an individual person is doing from a lifestyle intervention perspective. So they're working on their health or managing their chronic disease or addressing risk factors for chronic disease. And that will be aligned with the in kind incentives that they also receive. The other part, I guess the other important thing is that we want to provide people with information about how they're doing. So for some having a Fitbit might be why provide them with some additional feedback and information on how many steps are walking. And if I'm doing 2000 steps a day, maybe I could maybe I could do 3000 and that might be the first thing. So what we want to do is make sure people have that type of feedback in their in their care and as they try out different ideas to be healthier so they can know whether or not it's making a difference for them. For from a provider perspective in our model, we want to provide them with with resources that really honor their knowledge about what their patients need. So I guess I think the key thing in terms of our approach here is flexibility and choice. We want individual people on Medicare to have the flexibility and choice for the things that are most important to them. And we want our providers to be able to take the the information in the reports and the financial resources that we provide to them. And they then can choose how best to apply that to make the biggest difference for the for their for the patients that they serve in the community that they serve. Thanks. So just to be slightly more concrete. So how would a person sign up for an in kind incentive like presumably they're participating in the online community? Is there like a process? Like how does that actually work? Yeah, so there is a process to sign up to the community. That is there'll be an app that they they can download will have support for them to work through that process. The with what then happens as they then take on or try different things. For example, just just downloading the app and signing up is a really positive step. And so based on that they then would be eligible for for an in kind incentive. And they would have some they would have some choice there in deciding how best to apply that. And I might be able to go into even more detail with the model when we move to executive session. Great. Yes. And please I should have said this at the outset if anything that I'm asking you kind of goes into that territory please just indicate and I will follow up an executive session. Yeah, that's great. I really I do. I want to share it. I mean, I'm so excited about it. But I but I also, you know, I think it's be best for that. Thank you. So I wanted to talk about a couple of Vermont programs, which understanding this is a multi state ACO. I just want to understand how you've been thinking about the Vermont specific stuff and or whether you're kind of deferring that to North Star. And those programs that I wanted to touch on were the blueprint for health and sash, which is services and supports at home, which is a program specifically for seniors, which started in congregate housing and is looking to provide services app in that congregate housing and also Vermont information technology leaders and how you would see your programs complimenting those programs and whether you as the ACO will be directly interfacing with those entities or whether that would be left to North Star. So I'm very familiar with the Vermont blueprint for health. I've actually I've actually been following that for a long time and in my previous roles and many of my leadership roles were in population health and obviously is being on the on the board of a health plan. You know, we, we thought about how to better serve members and patients in the best way possible all the time. And frankly, the, I mean, I, it's been, it's been really important in inspiring to see what the state is done and how, you know, the bold steps that were taken in creating the blueprint. And I, you know, early on, we, you know, I reviewed the blueprint for health again, and I just saw a lot of alignment with what not only with what we're doing, but why we're doing it. And so I think that I'm confident that that there'll be that alignment will continue. I'm not as familiar with sash. And so with respect to that, I do believe that it's working with the team at North Star Health, which they've been amazing to work with, you know, over these past couple months. In fact, where we have a meeting with them related to implementation later today, one of our regular meetings that are scheduled and we certainly will once we get the ACO stood up, we will dig into that. Obviously, it's it's a super important aspect of care. You know, we saw, you know, we saw, I guess I would say there's a lots of opportunity there to be even better. And to support them and certainly in when you're managing your accountable for your partnering around the health of a population understanding long term, you know, the care that's being given in long term care facilities and supporting those facilities and the best care is really important. And then lastly, from a health information technology perspective, when you have an ACO across six states and I think we've got five or six different electronic health records and, you know, a number of state of health information exchanges, we know that interoperability is super important. And so part of our approach is, is we're talking to several companies that that focus on interoperability of health information technology so that we can provide and connected people to share the most important things about the patients that we're serving, but not to connect just to have all the data. I've done that before. One of my jobs was implementing an electronic health record at at a health system. And it's, it's, it's unfortunately if you ask you asking for all the data doesn't help you so what we want to do is actually get the right information to people at the right time, so they can, with their knowledge, being closer to the people they're serving, make the right decisions and develop the right insights in terms of what we should be focusing on next. Thank you. My last question is around the financial model information that you provided in your slide and I appreciate that you provided a range of shared savings. One of the questions I wanted to ask you is understanding that Vermont is a low cap cost Medicare state meaning our PMPM tends to be lower than much if not the rest all of the rest of the country. How do you think that interfaces with the shared savings possibilities and your estimates. So this was actually Vermont specific. So we're using your so what you say is Vermont specific. I guess my question is do you see there being as much opportunity in a low cost state than perhaps in a higher cost state where there might be more utilization that isn't particularly helpful to the patient. You know, I think the I guess. The way I've thought about that is. You know, if the model was let's let's make sure we document everyone's medical conditions and make sure that our risk adjustment factors are optimized and. I think the answer would be wow. Yeah. No, I think the it would be there'd be less opportunity in a low cost state either because the. You know, the population is healthier, which in fact the population of Vermont is overall when you compare it to other states. You know Hawaii is always up there. I always wonder about that, but that's probably a conversation for another board meeting maybe. But the the other thing is that it you know the if it's a if the benchmark is low because it's not a true reflection of how complicated your population is then that's that's hard to overcome. The reality for us is that's not our intervention. That's not what we're aiming to do. In fact, there's even limits on how much you can manage your your risk adjustment factor. Now we now we absolutely believe that it's important to have an accurate medical record. Mostly so that we can create the awareness and insights that providers need. But our intervention is actually at the root cause of chronic disease. And that works everywhere because even in fact the state I so I looked up the state of Utah's obesity and overweight rate a week and a half ago. And between 1989 and 2018, the only thing it's done is go up. Which means we've we as as a state in Utah has just gotten sicker and continue to do so. So we're mostly interested on addressing that and doing it at scale and doing it in a way that is in partnership with with the providers in in any area that you know county or region that we're we have the honor of partnering with. So that they can begin to make a difference in in those risk factors that are way upstream of all the, you know, the sick care that takes place after someone actually gets gets those conditions. So I hope that helps. Yeah, thank you. I'm all set and I'll pass it to someone else. Thank you, Robin. This is this is Tom Walsh and I guess I'll go next. If that is okay with everyone. Okay, great. Well, thank you, Mark and Mark and welcome to Vermont. I'm I'm as one board member. I'm glad that you're here. The model of care that you're talking about is something that when I was practicing clinician part of an interdisciplinary spine center. You're using some of the same language, you know, and and your language is hinting at some of the things with shared decision making and motivational interviewing and shared medical appointments that we worked on to and and saw some some success. So I'm glad you're here and I want the best for what you're trying to do. A little history about here in Vermont with health care transformation and accountable care. Our conversations within the state have often narrowed down to discussions around reimbursement and pricing. And we've some of the time have lost track of of. Assessing quality rigorously and outcomes rigorously and we're starting to try to do more and more of that. We sometimes run into difficulty with benchmarking issues because our state small. Right. And this the small number with with statistics becomes some people. Some find it problematic. But I was interested in reading through what you sent us about your efforts. To to track for depression screening. And I was wondering if you could just say a little bit more about that. How you how you want to go about that. Yeah. So the. I'm really glad you asked that question because this is this actually is a topic that's really important to me. The. And when I started in practice back in. The mid 90s. We were we were the first. Primary care practice the first practice at at the organization I worked at to. Implement having a behavioral health. Colleague be part of the practice so not not a consultant down the hall that you refer to but actually a team member that. That. That we could partner with to to better care for people. And. We ended up ended up rolling that out across the entire system integrating mental health into into primary care hugely successful. And. The way that we will start. And understand that there's. There's a lot of things to do and so we have to prioritize the work and we're super focused on actually just getting the ACO stood up with with the federal programs and and getting our getting our the practices ready. We certainly though. Have an overall approach of we want to be aware of how people are doing. And so there's there's a two question you know the PHQ two and the PHQ nine. That we envision. Using in the community that people could could fill out and ask the question. But we also believe that there are new things to learn here there are new things to learn about what does how does a better connection to people both. Those that you are that are in your life in person. As well as the community the community that we're creating across the ACO. You know how do those connections actually have an impact on depression anxiety mood disorders etc and I and I mostly am framing my my thoughts here for those things because. Obviously people who suffer from serious and persistent mental illness. They need a set of services that that require you know psychiatric care and support and and local services and you know they would certainly be part of a high risk group that market. Tyler talked about that that that we want to be aware of and make sure that our our clinic partners are aware of them and using every resource they have and every resources in the community to care for them. The greater the greater. The larger conditions are mostly around mood disorders and loneliness and so those are the things that we want to identify. And then. You know one thing that I learned with with the program decades ago is that. That despite all of our wishes that it doesn't it's hard to make to get at the scale because there just aren't enough people out there to care for you know psych therapists and social workers and psychiatrists and psychologists and so. I'm we're very interested in exploring how that you know how does that the community have a role to play here and are there additional partnerships. In the coming years companies that are innovating in in digital care and there's many of them out there it's little you know we have to figure out what you know what's working the best. But but we definitely want to review that and potentially partner with companies providing that that type of care so that we can really serve people at scale. I appreciate that and I I'm familiar with the model that you're just you're describing that you used in Utah and just an interesting piece we used a similar thing at. In New Hampshire and when we first launched we were screening for depression and we had a behavioral specialist in the hallway with us like you described. But in those early days of the people with a positive screen for depression only about 10% of them were seeing the psychologist. We it took us three years of work internally to figure out how to use that. And so I'm I'm really glad to hear about your your background with that because I think one of the things that I'd like to see more of in Vermont is. I'd like to see us be able to move to a place where we're more focused on outcomes that matter to patients and also with an equity mindset that it's people are popular. It's a popular topic right right around now but with those things in mind I think about like to stick with depression for example. I would want to be able to answer a question what proportion of my patients with depression with a positive screen for depression actually see a psychologist or participate in the community. Right and so then if the outcomes for the community effort are improving depression scores to go down. Then we know to move more people try to move more people into that right so it's what proportion of my population have a positive screen for depression. Of those patients what proportion have seen the care provider. What proportion haven't what. What number have ended up in the emergency department or admitted and terribly but importantly what what number have died. Because the ED visits the inpatient admissions and deaths are numbers that we don't need to benchmark against another location. We can try to bring those towards zero and if an organization is moving towards zero then we know that they're progressing that whatever they're doing is making progress and helpful and we can. I'd like to be able to do that similarly with diabetes what proportion of my patients with diabetes have an A1C level greater than nine and haven't been seen in the last six months. They're rising risk patients that are going to end up in your hotspot right and so. Of those patients how many in the ED how many admitted how many deaths and over time moving those numbers towards zero. They'll never get to zero but that's you know high reliability organizations that's that's a goal right zero harm or trying to move towards zero. And so I'd like to see stuff like that in the future and I'm saying that to you you all now like like foreshadowing those are the types of things. Hopefully when you're coming back year over year at least for the next five that we'll be able to discuss those types of things and see what you've learned with your community community outreach because I hope you're here. We need the Vermonters need options and they they need innovation and I'm thankful for your effort. So I hope that's helpful and with that I'll turn it over. I think Dr. Merman is up next. So thank you. Thank you Tom. Hi Mark and Mark Dave Merman. I'm a new board member. I am an emergency physician so not the primary care experience that you've had but just as an aside I to it definitely as a resident and boss to the member thinking a lot about how could we get this group of people together outside of the clinical environment to work together to improve their health and and share stories and strategies so I your effort resonates with me and in many ways there. I just have a few questions I think actually Tom and Robin brought up a lot of issues or not issues but questions that I had about your application. So I guess without going into confidential information my my concept of what the community based component of this is that there's sort of an app with with with some sort of way to communicate through this app with other people which which I would I would you know maybe characterize as social media and I think one of the things that we think about with social media. Sometimes is is is bias and bullying and exclusion and so I guess within these the the community component of your efforts how do you approach moderating issues like that and be an inclusive community. Yeah. Yeah. So thank you guys it's a really great question and it's the way there's a couple things that are important to do the first is when you when you join the community there is a series of steps that begin to establish what the community norms are so so when it's so that gets communicated to people as they sign up the the other thing though is to in terms of how we you know put some structure around the conversations that's in there's an intentionality in the design there to really focus on the types of things that that create curiosity that create create the and celebrate the ideas of giving and sharing and this this is of course then leads leads to trust and the presence of a relationship that's built over time. So we you know that's how that's how we get started and how we then continue to support that we have the the ability to monitor for behaviors that are outside those community norms and I think you know my I think through the I guess in my mind I always believe that and I sometimes get teased by my wife by this a little bit but I I always am looking for the good and assuming the good in people and so if we see those community norms not being followed we will have a conversation with them it might be a virtual but if needed if needed me we would contact contact them individually in the community you're you're you're pseudo anonymous you so you have a pseudonym that you're that is your user name but but you're not completely anonymous you know we know who who each individual person is behind the scenes and so we have that ability to have that intervention last thing I I have zero tolerance for bullying personally and you know I think that we've both worked in health systems a long time and we've seen what how bad that is for teams and people in care and so if someone is really stepping outside of the norms and crossing a line then then they won't be able to be in the community anymore so we're building out the capabilities do that at scale and but I but I would say the most important thing is really the you know how we actually going to interact with each other on a daily basis we we've had we have a small we have a small community already of people that are on the platform and I can tell you that people have asked hard questions and we've had but the community is a really great job of responding to those questions sometimes and even addressing maybe some ideas that don't have a lot of evidence behind them but doing so with curiosity and care and trying to understand what's what is any given individual concerned about the most in and asking that question it sounds like a really interesting idea I and I I think it has a lot of potential and excited about it I do I do still think that as this develops thinking about some of the challenges of how to address things like microaggressions in these communities and allowing patients an opportunity to identify those which can in itself be a challenging thing to do should just be really strongly considered to try to keep the community diverse and inclusive. I 100% agree 100% agree. Thanks that's all I have for now. Sure foster. Thank you. Can you please describe any revenue sources you have beyond what was described in your slides. We so in terms of the company overall we've had the initial an initial funding investment that's been made and that but beyond in terms of the revenue for the clinical revenues it is right now it is through AC the ACO is that main source of revenue. You have any operational revenue. Do you have any anticipated non clinical revenue help to discuss these yeah and the executive session. Do you have any revenue from pharmaceutical companies. No. Do you anticipate any revenue from any laboratories. Do you anticipate monetizing any of the data that you'll be collecting. No. And by you I mean gather or any partnerships with gather you know anyone associated with with gather not just gather itself. Do you anticipate sharing the data or using the data on behalf of any other third parties. No no we I mean we are go our data primacy is is very much governed by HIPAA and other privacy regulations and so that all be managed through through business social agreements and data sharing agreements. Do you anticipate monetizing the data in any way. When you maybe to clarify in question when you say monetizing the data. What is are you specifically referring to like we would sell the data to somebody for for a price or selling the data or using it on others behalf. No I mean we as we as we apply the clinical model and the and the community you know we certainly there's a lot to learn about how these interventions are going to make a difference in people's lives. But that learning will be applied to how do we just make the community better and how do we make care better and how do we how do we share the clinical information through because there's an appropriate medical need with our with our care providers that are part of the ACO. I forget what slide number was but on the budget and financial model slide. You had projected Vermont beneficiary in kind incentives and shared savings with Vermont providers of 1.495 million. Could you break that out for us in your projection of how much of that is in kind incentives and how much is shared savings with Vermont providers. Yeah. Mark do we do we have that detail. We can we can have it by the executive session. Yeah. I'm going to your submission. Page 2 question 6. That's about legal actions taken. I want to broaden that a little bit. Are there any investigations or legal actions potentially threatened or pending relating to the entity any of the employees or any of the investors. There are no legal actions related to the to the entity. You know specific to employees I know I think that that. You know I guess I don't know that I mean I don't know that answer and turns out we have 50 different employees so I I'm I'm not sure I know it can know that answer. We can get that detail for you. Yeah. As quickly as possible. I don't I don't I don't think we've been we've been attuned to that yet. Yeah sure it's the best of your knowledge and you probably have a like your reporting requirement on that I would think if there were any actions. Yeah. And what about the any investors. I think we'll get that. Let's go back. I guess I guess I just to clarify you're you're asking are there investigations from HHS OIG DOJ or others. Is that what I'm understanding. Correct. Yeah. Yeah. I mean I think we can answer that question. Yeah the answer. Yeah. On all the fronts. Okay. Thank you. Thank you Mark. You may have said this and I might have totally picked up on it but could you just describe for us what lifestyle medicine is. I think I get the gist but I appreciate a little bit. Yeah so. So I mean lifestyle medicine is is a it's a series of of interventions that I think many of us kind of we know. We know. You know things like. I should get I should eat a diet that consists of. Lots of plants. I should not I shouldn't be eating a lot of refined sugar you know. I shouldn't I shouldn't drink excessively. You know there. I you know I should get regular walks I should try to walk a little bit every hour. And. These things have been shared in medicine usually in the context of you go to your annual exam and and your provider may have a couple minutes to address that or maybe you're going to a specialist and. And it's you know you're going there because of your knee pain and you know the surgeon or their clinical team may may actually talk a little bit about about addressing some lifestyle things. But they're very hard to adopt and so when we talk about lifestyle medicine or our model is we want to create. Create additional knowledge create support for trying some new new things and create the awareness of how those things are actually affecting each and every person's unique metabolism. And so that's that's what lifestyle medicine is it really is doing the things that gets to the root cause of disease as opposed to prescribing another pill or advising for another procedure to be done. That really is just treating the condition and the symptom as opposed to the cause. Thank you that's helpful. On page nine of your submission to gather submission it says quote we support coordination across the care continuum comma which promotes appropriate utilization of care. It continues on but how do you support care coordination which promotes appropriate utilization of care. The way that we'll do that is we'll start with just by creating awareness and so. When we've talked when we talk to providers a lot of them share that it's sometimes very hard for them to know when their patients are in the ER or when they've been in the hospital. And so you know what we will be doing is providing clinics with that knowledge so that when someone does hit the emergency room. The team can then engage and reach out to the patient to see what needs there are after their emergency room visit. Or if they didn't know that their patient was transferred from the hospital to a skilled nursing facility we would make sure they would know that so that they can then. Activate their care management teams to make sure that they're connecting with that with that care facility or connecting with the patient at home doing some of the simple things like just reviewing the medications that they were discharged in and reconciling. You know if there are any if there are any. Contra indications with some new medicines or making sure that they have a really clear plan. Probably the most important thing is that you've just you've actually just reached out and made that human to human connection in that transition so that people have an opportunity to ask questions and and kind of figure out what the next steps are. So one thing might just be me but how does that promote appropriate utilization of care. It sounds like it's coordinating care but how does that promote appropriate utilization of care. Yeah, so I think. Well, let's just say that it. It depends on the. On the on the circumstance there so there. There are events that happen every day in in the care of a patient that. You know sometimes you're responding to an acute utilization event. And I guess what I do in this what I was describing is that when you had had one of those acute events. It's super important that you begin to connect with that person even more closely from a practice perspective and it's that it's that outcome that then leads to the go forward. Better utilization of care because we've had, you know, in that follow up to the hospitalization, you now have a modified care plan that reinforces. You know, reach out to the community reach out to the clinic before you go to the ER if you have a question. And so that that's that's where that a more appropriate utilization comes into play mark. Yeah, it's that and I think we're also aimed at reducing readmissions and part through what Dr. Pre soccer offered. Pharmacist so largely medication reconciliation is important and management post discharge. We intend to partner with our ACR participant with. And making sure that care plans. Especially post discharge there's visibility and then there's there's assurances of what should mark be taking that it marks out of the hospital. And Mr. Foster I'd also add is like one of the quality measures that will track is unnecessary admissions to the hospital. By people who have multiple chronic health conditions. And so that that's another that'll be a metric that we're that we are our following and then providing that information to the providers. So on unplanned admissions is would be is how that that quality measure is worded. And without getting into the substance of that we can just answer yes or no. Have you provided have you obtained. Legal review of the types of in kind. Incentives you're providing to patients. Yes we have. And have you already I thought you referenced somewhere the compliance training of you guys already provided training to your employees. We have not done we've not. Oh Mark go ahead. No so we will before the start of the ACO year we needed to finalize our our actual application and become an ACO at CMS which happens in December of this year. I don't think I have any other questions for the public portion of the hearing. I'd like to turn it over to the health care advocate for any questions or comments that they may have. Thank you chair Foster. Good morning still. Mike Fisher health care advocate. I'll have a few questions and then my colleague Sam Pish will have a few questions. So first I think many board members asked questions in line with questions we had framed up but. So some of these will be sort of follow up questions. My first questions are kind of in line with the questions that member Merman asked earlier about the the app or digital focus of this approach. And so maybe my my first question is you know given this population and its range of abilities and. And not being digital natives. Do you think this is what factor does that play in an online approach. Yeah. So I think that the. It is a factor but I would say it's a factor for everybody of every age and of every generation. When you think about when the Internet was created. Most I mean if people who are 65 to 70 years old today they actually were in their mid almost mid career like 50 55 years of age and so. When you look at the data on the use of technology by people who are on Medicare it's it's actually always surprisingly high to people because you have the. Assumption that it's that it's going to be low but in fact a lot of people are able to use it. So that I think for us the most important question is how do we make this as friction free and easy as intuitive as possible. So that people who are interested in getting engaged in the platform that that happens in a really really easy way for them. And I think that our approach it certainly applies all the best practices that our technology team has has experienced over the years as they have built this up. And we will learn as we go forward as to what makes a difference to individuals and I can tell you that our conversations with our provider partners have been really great in this area because they. They have given us things that that and shared ideas with us that they have used for many many years in engaging their patients in different types of initiatives. And just one thing to add it's in our incentives I mean the beauty here is let's say we didn't exist let's say this we never happened. You'd have zero beneficiaries they still have Medicare they're still in Vermont you don't zero beneficiaries that had any of this. And so I think it's helpful to think about the counterfactual here which is exactly what SSP or any ACO is intended to do which is if we did the current status quo. No one's you know talking to anyone and so I think from our end. And I came from CMS I am well aware of. Opportunities across that population. And I think we're working to address that whether it's financial whether it's digital literacy literacy etc and we're competent or cognitive the issue and hopefully we're competent. Appreciate the question. Yeah I appreciate that as well I. I think this line of questioning is more is it apt to work in my mind. And and. And I think I'll let go of it but I but with a statement because others have made statements I just want to recognize that that the more time I spend on this thing. The more depressed I am. And we're all spending too much time on this thing and I think an approach that asks people to spend more time on it I just think we have to be careful of and you know that's more of a comment you know have to have a response. No it's fine. Well I think we're in agreement with that there's balance to everything and so we are looking for that balance for sure. I also know that every intervention that we have done to try to address the growth of chronic disease in this country has not changed the trajectory and so. We were this is the next swing at how can we help people. Feel empowered have the knowledge have have the information that they need. And consuming it in a way that works best for them to then take those steps to to address risk factors for chronic disease or better manager chronic disease and do it doing it at scale at a scale that. Just won't be achieved there just aren't enough primary care providers out there to say you know so I've seen plans of of if we just had everyone get a primary care provider then this would be fixed but the problem with those plans is there's not enough primary care providers. And so I I I really miss first I think it's a great a great point and one that we we shared that concern and also hope that the type of interactions are ones that actually create a different outcome than than the feelings of depression. And just just to add to sorry I think we're not we're not an ad based company and so your interactions on I'm guessing your phone and social media are based on ways to get you to engage in a lot of algorithms that show you content to ensure that you you do respond and share. That's not our model our model is actually to ensure that you're healthier. And so our incentives are actually to help you walk rather than help you spend more time clicking on certain articles that they're engaging discussions that's actually not positive for your health so I think looking at the existing social media model and applying it here. We certainly learn from it and we understand that that's not our that's certainly not a health model that we're adopting or trying to encourage. I was trying to move on from this. It's a good question because I think it's things that we thought about and I think it's I mean partly we were happy to engage in that. And I think it's probably chair Foster's questions around data and we're kind of all those things and I think we're happy to engage the board and especially in a executive session it's helpful. What percentage of your business do you expect to be in Vermont? In other words, I've heard the 5000 estimate for North Star. I think it's just North Star. How big do you expect the other states to be? So the our total enrollment is 15,000 so Vermont is one third. Okay. Can you provide some additional information regarding your leadership structure and compensation for administrators. And staff. Yes, our leadership structure is I'm the executive director. Mark is quality assurance and compliance. We have a medical director, Dr. Jim LaBelle, and we've got a director of community. Mr. Taylor. The interns of compensation of the. The I think that if we'll provide that an executive session. Great. Great. Not surprised that that makes sense. So I know in your narrative, your discussion about. Your goal to help overcome barriers to access and. And so I guess what resources are available to help. Your beneficiaries overcome barriers. So being part of the community, there are providers are in the community. And so 1 of the approach to overcoming barriers is that when you join the community, you're getting. You're getting expertise from everyone who's part of it. The. The other thing that I that I know from being in practice is that. The when you have patients that are engaged in the plan and engage in their own health and. They are great patients to have those are the best families to have. And you know, so I actually believe that are. That over time. By creating more engagement that that that the platform will support providers and actually being able to serve more people. On a per provider basis. Now we have to prove that out. To see if that would happen. But the most important thing is that. Information that that maybe people that we're thinking I need to make an appointment in clinic for to find out they can now get that information themselves through the community. Or through and through the information that's flowing to them about how how what they're trying is making a difference. And just add, I mean, we have targeted things across the ACO, let's say prescription drug costs, which is a common. A common problem that we've seen beneficiaries, you know, ask for assistance on. And so I think in that scenario, when people qualify for extra help, we want to make sure a that they're aware that that exists. Be what the process is to access that and then see, you know, where essentially then they would then qualify. So as they choose plans year over year, you know, ensuring that they're aware of. How their entitlement and how their benefit of their Medicare benefit. It really is something that they can access. I think from the state perspective. If someone qualifies for Medicaid, I think I hope that we'd love to work with you to understand, you know, how patients that do qualify for Medicaid. Could access Medicaid. And so I think those are gaps from an access perspective that we're interested in and advocating for in partnership with you. Well, so thanks, Mr. Teller. That's that that's that's exactly where I was going as you as you look at the population of patients at North Star who are on traditional Medicare. Have you evaluated how many of them have secondary coverage? Yeah, so I mean, whether it's Medicaid or whether it's a medigap or medic yourself, mental program. So we don't have the patients yet. So I think one quite, you know, I think some of this is a time issue, right? So we don't. We won't have an assessment of those patients before really January, frankly. So the way it works in general is we don't sign a contract with CMS or any kind of data until December. So, but I mean, keep it again, keep in mind that this is the we are incentive to do the things that would help the set of beneficiaries. And so I think from that end, whether it's a medigap plan or whether it's Medicaid, we'd like to. Ensure that the right the right choice of care is an option for people, but it's something we're looking for. Yeah, all right. I think my point is probably well made for those folks with no secondary coverage. It may look like a lack of engagement to the provider and and actually be an inability to follow the provider's recommendation. That's what we see. And any kind of discussion about patients as not being engaged or not or somehow not being invested in following the recommendations of providers without an evaluation of that, I think. From my perspective is often not appreciating what is really going on in their lives. And who's the right office? If we identify the set of patients, you know, may qualify for Medicaid. Is that working with you? Like, what's the right approach there? I'd be happy to make it real. Talk in the future about, you know, Sure. Being of service to, you know, we are of service to all of our monitors, but we should have that conversation afterward. Sam, why don't you go ahead? Thank you. Thank you for your answers. Thank you. Thanks. Good morning, still. Sam Pysh, Health Policy Analyst, also with the healthcare advocate. Following up on a question that was chair Foster raised regarding your approach being rooted in lifestyle medicine. I just wanted to ask you to respond a bit to a concern or critique of lifestyle medicine and that it might not fully acknowledge or address the role of structural factors. Like discrimination, poverty, lack of stable housing. As I, I think it's our view that those factors fall outside or not completely explained by, you know, behavioral choice. So I'm just wondering if you could respond to that. Maybe can I just, Mark may have an answer. Go ahead, Mark. I mean, just to clarify, I mean, what is the point that there are other structural, there are other parts of someone's life that may affect their ability to to execute on lifestyle changes or maybe I can maybe clarify what you would, like, the problem and then, like, maybe get a question for me. Sure. I mean, I think what I hear a lot, kind of a theme throughout this is it's health, people to make better choices. And I think there are factors that limit folks ability to make that choice. And we're not always as a as a public and a collective, not always empowered to have the agency to do that. And that there are things holding people back that are outside of their individual control or capacity. So I'm wondering, like, how you address that issue or if that's a part of your model. So I think this is, I think this is why the partnership with with each provider in the community is so important. So you're now getting to the knowledge that that, you know, that a each clinical team and their provider and their care management staff and social workers. It's really important for them to know what's what's going on from a social determinants perspective. And it's why in our model, we really prioritize and believe in providing information and resources. Not in the form of it's a specific program. And you must do X, Y and Z. And then this happens. But provide the resource to the to the people that that have the most knowledge to then use that. In the right way to serve people in the best way and to address their most important thing. If you are not, if you are not sure, if you can afford groceries, then and you're having pressure with whether it's food insecurity or housing insecurity or economic insecurity. Your ability to to to to try a new idea is is really limited by the fact that you have these other things. So I think I think part and parcel with Mr. Fisher's comments. It's going to be super important. That we make sure that that this type of evaluation is taking place with clinical teams and to the extent that we can provide that information. Or maybe provide data that provides insights into this. This group, this particular patient. Might be experiencing something new so that you can there can be some outreach. That's that's what we would want to empower. Yeah, I think even just bringing back to the community. You know, I think in today's world. I would be interested in knowing how in Vermont. I would be interested in knowing how in Vermont. I would be interested in knowing how in Vermont. You know, let's say I did have this issue. You know, where do I turn? And is there a group of people that I can already access to ask that question to other than social workers are going back to the system. And so I think that's what we're trying to enable, frankly. And so I think to think about it as, you know, you only have a limited set of social workers. And other others in your community. And I think to the extent that the communities and others that have gone through this or know someone that's gone through this. You know, may have a better suggestion on how to address, you know, any of the social determinants. Mentioned. We think is, we think is a valuable part. Thank you. Appreciate it. That's that's awful. We talked a bit earlier about shared medical appointments and I imagine this is probably a new care model for a lot of many, many Vermonters. So I'm wondering if it seems like this platform is going to be online. So I'm wondering if you could speak a little bit more about that model and how patient confidentiality is maintained. And how you get buy in from folks to do that. Yes, so if in the model, if we, if there is an instance where someone would wants to have a, a one on one conversation with, with a provider. So let's say that there's someone said, Hey, I'd love to talk to a dietician about some things that I could do. You know, we could, we would facilitate that either number one by talking with our partner, the clinics who are in, in the community to see what's going on. They want to reach out and provide that resource or they could get connected to a private one on one conversation with a dietician who's in the community. Thank you. That's helpful. In the narrative, you also talked about engaging patients in culturally competent ways and coordinating solutions to overcome any barriers to access. I'm just wondering if you could concretize that or talk a bit more about how that operates in practice. Thanks. Yeah, I think this is really this. This actually has been really informed by our early work with the federally qualified health center in, in another county. And one of the things that we realized is that we need to be able to do that. I mean, there are just some things from a culture perspective that, that even as a provider that if I, if I work to understood, I still would not ever have the same level of empathy and understanding. As someone who is like that person in the community. And, and so it was really, and this is, this is, these are stories only from our early work with the federally competent health center. If I, if I work to understood, I still would not ever have the same level of empathy and understanding as someone who is like that person in the community. And, and so it was really, and this is, this is, these are stories only from our early work, but it was really, it was really gratifying to see how a person who is illiterate. Where, and they don't speak English, and they are undocumented yet they get, and they have a chronic condition, and yet by being on the platform, and by being able to have access to information and others who could ask, answer their questions. That, that made a difference for them. And so I, I'm excited about this because I just don't believe that as a primary care provider, I would, I, you know, even with awareness, I still would never be able to, to have that same level of expertise and empathy and understanding to respond to someone who is in, in the, in the circumstance that's similar to what they are experiencing. And that, and so in that mind, the community does become a provider that is more culturally empathic and competent. Does your group do any type of trainings for implicit bias improving cultural competency that sort of thing or plan to do that when you come online? So, you know, so many our providers, you know, we're across multiple states. So I think from the ACO's perspective, especially with how we interact with our beneficiaries, you know, we ensure it's, that's language, you know, the big deal for us, you know, ensuring that there's multiple languages, not just English and Spanish. Beyond that, I think, I think the, the concept of implicit bias or others, you know, these are operating practices that see patients daily. We defer to them. I think, you know, a big part of Medicare in general is that physicians and providers practice and not, you know, the regulator. And so in our case, we're regulated by CMS. And so in that view, it's up to them really to ensure that their care models are trained to identify implicit bias and trust them. We do the things that we can control and that others handle the parts they can control. Okay. This is my last question, at least for this session. We may have questions from the executive, but I'm wondering if you could provide a little more detail for folks that, for beneficiaries that live, I mean, Vermont is a state where not everyone has regular wireless internet has cell service, you know, it's a very rural state by and large. And I'm wondering what accommodations you make for folks that might be in that situation and for folks that have disabilities or other access issues, what accommodations you make for integrating with your model. Yeah, so we've thought a lot about that, because we recognize the population we're treating and, you know, similar to how I, we answered Mr. Fisher's question. We will have pathways beyond just the, beyond just the app to ensure that people that need access to these incentives and to this care that's not covered through Medicare, get access to that. And that main point of access is through the provider. And so when we talk through in the narrative about our partnership with our provider, it's critical, right? So the point right now, none of the beneficiaries know who we are and likely they will not know who we are, you know, throughout the year. They've done with their providers though. And so I think where our point of care comes in is that the provider office and to the extent that people adopt the community and people join together and really see the value in connecting with each other and others, that's our view. Hopefully that helps how we thought about it. Thank you. I'll turn it back to you, Chair Foster. Thank you. This time I'd like to turn it over to public comment. And folks could use the raise your hand function. I'll try and call on you in the order in which your hand is raised. If there are any questions or comments. Okay. There seems to be no public comment today. And with that, if there is a motion to move to the executive session, please let me know. I will make said motion. I move that we go into executive session to consider the portions of gather health budget submission relating to the terms of the ACO agreements with its providers that are exempt from access to public records provisions of the Public Records Act. And is there a second? Second. And all those in favor of moving to an executive session, please say aye. Aye. Aye. Aye. And any oppose, please say nay. And the board has voted unanimously to move to an executive session to discuss the confidential portions of gather submission. Mr. Kraken. Is there anything else we need to address? No, I don't think so. There has been a separate invite circulated to board members, relevant staff, gather health. And the healthcare advocate. So, what we'll do is we'll sign off of this meeting and sign on to that second executive session meeting. Professor, I have a quick question. In prior hearings, we've identified the people who should go into executive session, specifically board members, ACO staff, the healthcare advocate. I don't know if that's required, but I just thought I'd raise it. Yeah, I think that's good as you saw. So, the executive session will be the four board members who are present here today. Mr. Attala, Dr. Brasiker from Gather Health, your attorney, Mr. C, would be myself and perhaps our general counsel. And ACO staff will be Marissa, Julia, apologies if there are other eight board ACO staff that I failed to mention, and healthcare advocate, Mr. Pysh, Mr. Fisher, and of course, Susan Barrett. So, he's welcome to join us all. And lastly, we will have a court reporter over in the executive session. It's a separate transcript that is kept confidential. Great. Thank you. So, at this time, there is a login link for those who are permitted to participate in the executive session, and we should move on over there. And when that's completed, just for others, we will come back to this session and wrap up the board meetings. Thank you. Hi, Maggie. Are you all set or are you waiting for backup? Not more set. Okay. Okay, we can go back on the record. On the record. Thank you. Are there any additional comments or questions for the gather folks? Great. Well, thank you both for your time and answering all of our questions. You're very thorough, and we appreciate it very, very much, and we're excited that you're interested in Vermont. It's a great state, and we hope that you have a lot of success here. At this point, I'd like to ask if there's any old business to come before the board. Is there any new business to come before the board? And is there a motion to adjourn? So moved. Second. All in favor, please say aye. Aye. Aye. Aye. Any opposed? Hearing none, the motion carries, and the meeting is adjourned. Thank you.