 Good morning everyone it is March 25th and this is the Senate Health and Welfare Committee and we are today talking about the global commitment waiver and the all-payer all-payer accountable care organization update with Ina Bacchus our health reform director in the AHS and Elena Barubi from the Green Mountain Care Board. So committee before we get started just to let you know two things one I guess one is for witnesses and the folks who are watching who are potential witnesses to try to be sure to no don't try but please do get your testimony in at least 24 hours before the committee meeting. Nellie has a is the one who posts this and so it takes her time and in the beginning of our meeting she is extremely busy and then she's busy throughout the the meeting time so it's important to get that testimony and and committee members we're we're been pretty good about being on time so no comment there it's good. Senator Taranzini will be a bit late Senator Cummings is not here for personal reasons so we can we'll begin the committee with our our loyal three no we're good so welcome I I'm not sure you two have you two coordinated at all or we I think you have at least on the accountable care organization piece so I'll turn it over to you and let you introduce yourselves for the record and then we have testimony from you on our webpage there you go. Good morning for the record my name is Ina back as I'm the director of health care reform in the agency of human services before we get started I I do want to clarify Senator Lyons we we we discussed that we would present the global commitment testimony at another time so that we could use today's time in full for the all-payer model discussion. Thank you for that reminder I yes I know we did that and I just it was my on my end I failed to let Nellie know that that would that would be the case but we're fine. Great all right okay and I am Alina Barribee director of health systems policy at the Green Mountain care board. I I think that it would be the practice for me to share my screen as I present. Okay so Nellie can you give Ina the share screen. She should already have that capability. Okay there you go. Which one are we looking at that we have two we have one under your name Ina and one under Alina's name. This is the one that is under my name and hopefully you're able to see it. Yes we can. Great today and Alina and I certainly can be co-presenters and if that's all right with the committee and for for me to invite Alina to fill in where she has particular expertise and vice versa as we talk through the information with you. The the topic for today's testimony is the all-payer model accountable care organization agreement and I think there are a few things that we'd like to focus on certainly providing some description of what this agreement is and why we are pursuing this particular health care reform activity in the state of Vermont as well as sharing with you some of the experience at this time in the agreement and where based on that experience we have identified areas for improvement in the agreement through what we published in November at the agency of human services which is called the implementation improvement plan for the all-payer model agreement and that plan it has a number of recommendations in it for how we can improve in our implementation of this model both in terms of our own success here in Vermont but certainly in keeping with the contract that we have with the federal government so that Medicare can participate in this model with us which is something that I'll also spend some time talking about the uniqueness of that contract with Medicare and the importance of Medicare participating in payment reform on Vermont's terms. To ground the conversation I want to talk about the kind of health care reform that the all-payer model is our health care system in the United States and in the state of Vermont is a large portion of our economy and is a complicated system and so there are multiple areas of health care system reform that at different times require different attention. The all-payer model is a type of health care reform that focuses on payment reform which we'll talk more about and delivery system reform. Payment reform intended to curb health care cost growth and delivery system reform intended to improve quality in population health and also to curb health care cost growth. This all-payer model in our agreement with the federal government for Medicare's participation in it is not a is not a health care reform project that collects money differently that finances health care differently than today or that provides for health care coverage differently than today. This is a model that is not focused on those aspects of the health care system. Another place where this model doesn't currently have an influences with respect to prescription drug spending and prescription drug and prescription drugs as a driver of health care cost increase. So the while the the model is incredibly important in stabilizing our health care system in curbing health care cost growth it is not addressing all areas of the health care system as a reform as a reform project. The all-payer model is focused on changing how we pay for and deliver health care and that is because the health care system today is largely it largely remains a fee for fee for service system where each and every service that is delivered through the health care system is reimbursed and it is reimbursed regardless to quality or outcomes for an individual. Instead of reimbursing for each and every every service regardless of the quality or outcomes the all-payer model is moving Vermont towards a statewide system of care in which we in which we establish a budget for the health care system through participating in alternative payment models that and that we and in fact we provide for the health care system spending prospectively and this is happening in our Medicaid program now and I will elaborate on that as we go through the presentation but we're trying to move Vermont towards a system of prospective payment upfront payment for health care services that then providers working together to coordinate quality and care work within that budget and and are at risk if their costs of health care delivery exceeds that exceeds that budget. This budget very importantly is tied to the quality of care delivered and to improved health outcomes which which establishes it firmly within the within the thinking of an alternative payment model and an alternative to fee for service payment model that is not simply a capitation or a return to to what you may know as the HMO area where health care spending was simply capitated and then there was an incentive to reduce the delivery of services or perhaps to for lack of a better word skimp on the delivery of services this model really differs from an HMO model or the HMO models that were active in the 1990s because this model ensures that care is delivered in a high quality way that appropriate services are delivered and that their services aren't being denied to individuals that that require them. The federal government is also very focused on paying health for health care differently and through the health care payment and learning action network the our partners at CMS look at moving away from fee for service using the framework that I'm sharing with you here and you can see that this framework for alternative payment models it really describes a trajectory that moves away from what I described as fee for service payment without any link to quality or value towards a system where payments are made on a population-based basis and payments are linked to quality and are linked to value. In Vermont we have made progress all the way into category four of this of this framework and so naturally moving left to right the framework is moving towards a system that is as divorced if you will as possible from as possible from the fee for service system that we have today that drives volume of services and that doesn't necessarily focus on the best quality and outcomes. In our Medicaid alternative payment model program in particular we are able to provide for um population-based payments that are paid prospectively to providers. Whoops, I didn't mean to move on so quickly um but uh I will. So Vermont has Vermont has an agreement with the federal government and it's through this agreement that we are we are endeavoring to realize the shift away from fee for service to an alternative payment model and I want to emphasize that we are we are in a very small group of states and we very uniquely have Medicare participating in our state program on on our terms so consistent with Vermont's vision for shifting risks to providers for paying providers differently. We have more work to do to work work to do to structure our Medicare program specifically so that it can mirror more so our Medicaid program. I'll talk I'll talk about that as we continue through but I do want to highlight the importance of Vermont being able to innovate and include a federal payer program. Medicare um which Medicare largely pays fee for service um nationally Medicare um doesn't doesn't do things differently it's very standardized so for Medicare to be operating differently in our state is is a very important relationship. Now our our model in Vermont is called the all payer accountable care organization uh model agreement and our so accountable care organizations are central to our agreement with Medicare to reimburse providers differently than fee for service. Accountable care organizations are composed of and led by healthcare providers who have agreed to be accountable for the cost and quality of care for a defined population. These providers share governance and work together to provide coordinated and comprehensive care for their patients. Vermont again uniquely um has one ACO that's operating in the state of Vermont and you're probably you're familiar with one care of Vermont. It has one ACO operating in the state it is also unique in that it is a statewide ACO. One care has participants in its network that are that are statewide across across our state. Uh there we also have this is an ACO that includes hospital and physician practices as well as home health services as well as designated and specialized services agencies. The agency the ACO has a as a broad complement of providers and an incredible opportunity for those providers to coordinate uh care across across different care settings. Under the all payer model ACOs are organizations that can accept Medicare's fee for service alternative payments. Again Medicare is agreeing to pay differently than fee for service here in Vermont. However through this agreement the only way Medicare can pay differently or will pay differently is by providing that alternative payment to an accountable care organization. The accountable care organization is also a structure that can share in savings between its participating providers. That structure allows allows for those shared savings to be shared and for providers to work together whereas if providers are not coordinated and organized in the ACO there are concerns for providers in in this regard when it comes to antitrust the law and gain sharing provisions. In Vermont's agreement we we through our agreement can see and and can enjoy Medicare participating differently in healthcare reimbursement in our state. In order for Medicare to do that certainly the federal government is looking for things in return for that flexibility and the federal government similarly to the state of Vermont is interested in healthcare cost growth moderation. So we have through our agreement targets for healthcare cost growth moderation that are specific to Medicare but that also apply to all payers that are to all payers and to healthcare spending on behalf of Vermonters who are covered by all payer types in the state. The the this is important for Vermont for our goals of moderating our overall healthcare spending growth it's also important to acknowledge here that Medicare is making a bet that when other payers are participating in an aligned payment reform project that that project will have more momentum and will have more likelihood of success. When we negotiated this agreement with the federal government in now 2016 there was the Center for Medicare and Medicaid Innovation which is an innovation engine that is that is focused on developing alternative payment models and alternatives to fee for service their very strong hypothesis was that a model that includes these alternatives across different payer types so instead of Medicare being the only coverage that pays differently Medicare is joined by Medicaid coverage in paying differently and by commercial coverage in paying differently because in our state and in our national healthcare system we don't all have the same type of healthcare coverage there are providers are being paid differently by different types of healthcare coverage and by different and and and also through a variety of different contracts with commercial payers like Blue Cross Blue Shield and MVP as examples. Can I ask a clarifying question of Ina? Absolutely okay thank you Ina this is Ruth if you can't see me thank you so I'm looking at the the percentage growth that is agreed on in the model or in the in the agreement there's for for all payer the compounded annualized growth rate of 3.5 percent and then the Medicare growth rate target 0.2 percent below national projections could you explain those a little bit because they're not obviously comparing apples to oranges in terms of what there are a percentage of correct? Yes that's correct that's that's absolutely right um the all-payer growth target is first of all we we measure this growth based on those services that are included in the agreement and Ina may elaborate on this as well but we refer to those as as total cost of care so total cost of care roughly looks like hospital and physician services it also does include mental health and substance use disorder services but if you think of it as a a bucket of services that are subject to this growth rate that's what's included in the all-payer growth target it's a it's a bucket of services that's largely similar across the different participating payer types Medicare Medicaid and commercial payers and again it looks it it it can be categorized as hospital and physician services it doesn't include prescription drug spending as okay so then what is that that's the 3.5 percent that's what you just described okay so what's the 0.2 percent measured on the 0.2 percent below is measured on the same bucket of services so the services are the same but what what Medicare is looking for is for Vermont's Medicare spending so hospital and physician services only not part d Medicare for that spending to grow 0.2 percentage points below what the national projections are so it's not actually growth below the actual Medicare it's growth below projections of Medicare spending for the the performance period of the model agreement okay all right that's helpful and I'm assuming at some point you'll get to how we're doing compared to these in your presentation like are we hitting these targets basically I think that Elena is going to be able to talk about the Green Mountain Care Board's role in specifically in tracking progress against these targets and yes we will be able to okay thank you as I was as I was explaining in terms of the importance of the of the multiple payers participating that's certainly something that we believe would improve that improves the incentive for providers to deliver services differently and to do so more efficiently if if revenue for providers is as aligned as possible across different payer types and if incentives are aligned as possible across different payer types then the likelihood that the delivery system will transform to live within those different changed incentives the likelihood is higher the other you know um before you get to the other important I think um the alignment has always been an issue in a lot of different ways maybe you could elaborate a little bit about what you mean by alignment among all payers and what what sort of provisions rules guidelines um we're we're talking about that'd be helpful and centered alliance could I ask a question as well of course interrupted thank you thank you and ena it's Cheryl Hooker um how do the hospitals fit into this I mean with hospitals still paying you know 85 percent of their services are fee-for-service how how is it fitting into um these growth projections and maybe the alignment will talk about that alignment so hold on that hold that thought um why don't we answer the alignment question first and then go right to the hospital question because that's a it's a slightly different I think so that's up to ena but these are excellent these are excellent questions and alignment is a very important concept in this agreement in multiple ways um because we have different types of payers in our system with different sets of rules and regulations providers have to have for lack of a better word elaborate systems to be able to meet the rules and regulations of all the different payer types that's one type of alignment that we're looking for in this agreement in in aligning the the rules of cross payer types as much as possible to include how payers are looking at the quality of services delivered by providers and that's one of I think the major I would call one of the major successes of this agreement for participating accountable care organizations we have a very aligned set of quality measures the quality measures are are all in service of improving access to primary care reducing deaths to suicide due to suicide and drug overdose and reducing prevalence and morbidity of chronic disease and there's been a very concerted effort for the quality measures to look as similar as possible for each of the payers that the ACO has a contract with so that there can be a clear message from those payers about where the areas for focus on quality are and so that there can be um that there can be the resources can be devoted um more strategically uh to improve in those quality areas versus each payer coming at the contract completely from their own um completely from their own set of of priorities and may perhaps not necessarily um not necessarily seeing the priorities of other payers and how working in alignment can can improve the ability of the healthcare system to respond to those priorities that's that's one type of alignment that this agreement looks for there's other examples of alignment that the agreement looks for to include the to include the aligning as much as possible in terms of alternative payment models so there is not complete alignment the payer contracts do look different in terms of of paying differently than fee for service however there are some some key principles in terms of the amount of sharing of savings that has to be realized in these payer contracts and some other some other key areas of alignment the agreement and care board does look in and has to look at the degree of alignment across the payer contracts as part of their role in in assessing the progress in this model and the degree of alignment in in payer contracts is also important for the purposes of administrative simplification for providers who are participating and and and again who have multiple payer contracts and to the degree that they can be similar or the same in what they require of the providers that is an opportunity for administrative simplification and and potentially saving is that do you need examples other examples i'm i'm asking the committee now because the the alignment piece can go on and on and on but i'm just wondering if if you have questions about some specific boots on the ground examples senator alliance i'm just wondering who determines these alignments if all of these payers are are doing different things who's going to say you know and do they have to agree that these alignments with what comes out of the green mountain care board the aco i mean who determines this so can i just can i just give you just an example of the stress about trying to do this and that is i can remember a committee meeting where we had all everyone in talking about alignment and we talked about one federal rule and how could we get private payers to be more in line with federal a federal guideline it's it some of it is by agreement simply by agreement between and among the the payers so and then because this is this is a voluntary the aco is voluntary all the way across the board so having we also have federal rules that need to be followed so then you're ask you're asking private payers like bruce and blue shield to adhere to federal rules and guidelines it becomes a negotiated process so it's the payer folks and in i'll let you carry it on further i just just that this we've been trying to align for a long time and it's not easy that the green mountain care board through this agreement is required to operate the medicare the vermont medicare aco initiative and through operating that the green mountain care board can actually shape that initiative so that usually medicare is is you can think of medicare is very rigid and and you just have to follow by medicare's rules because medicare is is a large federal payer and it kind of sets the pace in this case because we have an agreement with medicare the green mountain care board can actually shape how medicare participates in this model to a degree it has to be approved by the federal government it's not just do whatever you want but there is flexibility for the vermont medicare aco initiative to be tailored in a way and more aligned with how perhaps our medicaid program functions in the state and perhaps how our commercial programs are functioning in the state so that's that's a that's a really key aspect of this agreement whereas typically there would be nothing we could do in terms of a medicare requirement through this agreement we can we can shape how medicare participates and that is that is pretty unusual flexibility and i think it was senator hardy who asked about performance and in the agreement and and if we're going to talk about that i do want to talk about performance in terms of scale there are scale scale targets in this agreement the agreement looks for the preponderance of vermont residents to be attributed to this alternative payment model by the end of the five-year performance period and it looks for that because it's it's important that we shift payment for for providers as much as we possibly can in order for providers to be able to adjust their business models to a system where their revenue is where they're at risk for where they're at risk and where their revenue is not based only in a in a fee for service model and so senator hooker i think you were pointing to this by asking about how this is working when when many payments are still in fee for service and it it's it's a reality that a much of the system is still being reimbursed through the fee for service model and that we haven't realized our scale targets for this agreement however we and we and and the state of vermont received a a letter to that effect late in the fall and in part that letter was what prompted our implementation improvement planning process and and we replied to cms with recommendations that were included in our implementation improvement planning which cms has has accepted um as as a acceptable approach for us to try to improve progress in this area but scale is but scale is very important um because the the incentives again need to be aligned as possible for providers to have one one revenue model that relies on more and more more and more customers so to speak more and more services being delivered instead uh and instead of a model where their revenue comes uh prospectively and then they they are they have their revenue um it is guaranteed and then they work within that budget um it is very difficult to work in both of those worlds so to make the adjustments to live within a budget it's very hard to do that when you still in fact rely on fee for service revenue so that's why the scale targets are very important in this agreement and i want to talk about how scale is achieved and then talk about what scale looks like in our Medicaid program and how we can use that Medicaid program as somewhat of a barometer if you will for what things start to look like when you have more scale of participation this agreement um has a scale target the scale target is a function of individuals who are attributed to the accountable care organization and an individual isn't attributed to an account accountable care organization unless two things are true the payer has to be participating with an ACO so whoever my uh so I'll I'll use myself as an example I am a state employee and so the state employee um the state employee uh plan was not participating uh with the ACO previously they are now so previously I was not attributed to the ACO now as a state employee in the plan I can be attributed to the ACO because the state employee plan is my healthcare coverage and it has a has a contract and is participating with the ACO the other but my provider also has to be participating with the ACO for me to be attributed so if my provider doesn't doesn't participate with the ACO isn't a part of the ACO network then I won't be attributed even though my payer is participating so my payer needs to participate and my provider needs to participate for me to be attributed to the ACO and participation go ahead go ahead well I was going to ask you to talk a little bit about why is it that we can't have um a prospective payment system where it's just um related to the payer the payer is going to pay in that way whether or not a provider is participating in the ACO the well the the in this model the scale is realized by eight vermonters who are attributed to an ACO so for scale to be realized um the payer can't only the the vermonter has to be attributed to the ACO and largely the way a vermonter is attributed uh attributed to the ACO is if there is a provider participating in the ACO but I guess my question is that is this um I mean theoretically uh a payer a private payer for example or uh a Medicaid could decide to pay through an an all-payer uh system where it's a it's a payment per member per month but but the value of having it go be a ACO provider is the the collection of quality and clinical data that helps to inform whether or not this is a value-based program yes and those providers who are participating in the ACO can use that information to deliver care that is more efficient and is of a higher quality there the the Medicaid program is is attributing uh some vermonters um for participation in the ACO that may not have a participating provider however those but largely the attribution method methodology is through provider and that is the case for Medicare as well as it is for Medicaid Senator Hooker has a question yeah I'm just confused so your part you know of the the VSEA as part of the um as a participant in the ACO but you're not obliged to use participating providers correct as a as a as a vermonter I can I can choose whoever I want to see for my primary care provider um and if my primary care provider is not participating with the ACO then I won't be attributed but if you're a Medicaid individual does that provider have to participate in the ACO no um there are there are some Medicaid members that do not have a provider and and there's work underway to to align those Medicaid individuals with a provider when there isn't a provider there they can be attributed to the ACO okay thank you Senator Hooker did that answer your question was it was a clarity with that um yeah I'm just trying to um put these together it just sounds to me like a single payer would be a an easier thing to do but that's another discussion well I know think of go ahead no go ahead go ahead think of what think of the the the value that is associated with having a quality metric analysis in other words when treatment is given to the patient that information is collected and looked at and then gradually if it's a substance use disorder or access to primary care or it um related to suicide those are the things that are being measured right now it that information goes back into the quality database at the ACO and over time the treatment for those individuals improves mm-hmm so that I mean so that's something that's not and not included other places this is this is pretty unique uh to our to our work but isn't it isn't it dependent upon the pay or the provider's participation as far as the data collection that's a question for Ina yeah this so I have this bullet here that says participation is is largely voluntary and and it really is almost exclusively voluntary the the the one place where it's not is that the Vermont um department of Vermont health access does need to offer per our agreement we we signed a contract that commits the department of Vermont health access to offer an alternative payment model contract to an accountable care organization of course the department of Vermont health access has to it does it does have to offer that and wants to do so and we'll talk more about why it's beneficial to do so but I I highlight that um that if an ACO doesn't want to sign up with that it doesn't have to so for the most part this model is entirely voluntary it's voluntary for providers to choose to participate in coordination as an ACO it's voluntary for providers to join the ACO it's voluntary for payers that are not Medicaid so it's voluntary that for commercial payers to offer ACOs a qualifying contract a contract that would meet the all payer model standards if you will and therefore would collect the data from them from those providers but otherwise not the well um the providers participation in the ACO um providers in their contracts with commercial payers have um there are quality metrics included in those contracts with commercial payers um even if they are not contracting in ACO there are certain quality metrics they may not be aligned with the quality metrics that we're focusing on in terms of improving access to um you know the quality measures that have been identified in this model there are metrics between payers and providers the metrics don't exist only in an ACO contract this is I guess what I should say okay thank you so I want to highlight that providers who do participate can benefit from the option to be paid a different way and we saw this benefit play out in the uh pandemic when our Medicaid program I was providing upfront monthly payments to providers um if those providers had been being paid traditional fee for service through the Medicaid program and Medicaid beneficiaries were not seeking services as many were not during the pandemic those those healthcare providers would have seen their revenue fall away and we did see and healthcare providers have experienced revenue decline because people have not been seeking services in the same way during the pandemic and where people have a payer that's paying fee for service that means no no dollars are coming in the door if a provider is paid alternatively to fee for service and has a budget and has a budget provided up front that means the provider can continue to um be open uh that the provider can maintain its capacity to care for people when people may be returning um to seek services and it provides predictability and stability for the providers that otherwise would not exist if the only way that providers make make money or are paid is when someone walks in the door and and is delivered to service it creates a budget for our healthcare system can i ask a clarifying question on that so you said that medicare provided those payments to providers is that right did i hear you or was it Medicaid Medicaid provides okay the fixed payment yes okay so the fixed payments that go to providers that are participating in the ACO do they come from the individual payers or do they come from the ACO itself the the payments the the payment the the fixed payments are made to our for the ACO so yes then the ACO distributes them to providers correct okay thanks participation also allows for access to data and analytic analytics to support decision making and quality performance access to tools and resources that support care delivery that the accountable care organization makes available to participating providers access to funding to support more coordinated care and because the ACO the accountable care organization is a statewide network with a variety of provider participants there are shared learnings that can be that that are a benefit to participation from a statewide network of providers it's going back to the back to scale i said that we had not met the scale targets for the agreement we didn't meet the targets in terms of all payer scale we didn't meet the targets in terms of Medicare scale however here in this graph i want to demonstrate the scale of participation in our Medicaid program the Medicaid program again is offering fixed prospective payments to providers and whereas the Medicare program is is offering a prospective payment but it isn't fixed it's reconciled to actuals which makes it less attractive and more complicated for providers and the commercial contracts it include risk for ACOs but do not include prospective payments at this time where we are offering the most aggressive move away from fee for service and the most significant transition to a different Medicaid revenue model you can see that Medicaid participation is is by far in a way the most robust so in our Medicaid program we've seen the the number of beneficiaries that are included in this model grow significantly since first offering a model with the ACO and and that has stayed very high compared to the other pairs so when we look at how are we going we've we've been told we're not performing well on scale you saw that we're not performing up to the targets when we think about how we improve on those targets i think it we looked to and i think it continues to look to our Medicaid program as a model for how we might improve and in the Medicaid model i wanted to share a few a few pieces of experience and in and so the Medicaid model is not only a benefit for providers because the providers can rely on revenue through this model and it is predictable and stable also because the payments to the providers that are aligned in the ACO are fixed that means that the payer in our Medicaid program also experiences predictability and stability in terms of budget and planning in 2019 divan one care agreed on the price of healthcare upfront and actual spending was more than expected from the payer perspective this this is another benefit of the model the payer is sharing that risk the financial risk with one care and therefore one care has to pay for a portion of the spending that was in excess of the agreed upon price in the fee for service world if spending was more than the than expected the payer pays for that additional those additional services and that additional intensity of services perhaps it's a mix of more services and more costly services that drive the spending over what was expected if it's a fee for service model the the healthcare payer is responsible for paying more than what it anticipated in the in the alternative to fee service model that overage is not entirely the responsibility of the payer and in fact it is in part the responsibility of the providers which is what creates the incentive for the providers to manage more more efficiently but when when there are are patterns in care and so on that that cannot necessarily be managed within the within the spending again it provides protection to the payer in terms of that total of that total cost we also see another very helpful trend in the diva contract and again i i'm sorry to sound like a broken record but i think it's such a crucial difference in in our in our payment models and is also such groundbreaking experience that it's worth talking about where diva pays the aco prospectively instead of fee for service so it has it it's there are still some services that are paid for fee for service but that are at risk but there's a there's a large portion where there's only the prospective payment so when there's only a prospective payment we see that those providers who are receiving the prospective payment spend less than expected on the services that are within their control we that means that within that the providers are working within the budget to deliver care more efficiently and that that's that's a exciting trend for us to be able to see now at with three years of the prospective payment underway that when providers perceive a prospective payment the amount of services delivered within that payment are are managed within within the budget some more benefits from the Medicaid program in particular which i want to share because i because they these benefits really drive how we think about improving overall in our model we want to think about how we can make more aspects of the Medicaid program aligned with our other payer programs the the Medicaid program has has provided more certainty in budgeting there is more payment predictability within the program which builds stability over time the prospective payments again that trend really shows that there is a lot of potential in changing the financial incentives that when the financial incentives are changed that care is managed differently within those financial incentives we've also seen through the Medicaid program that there have been incremental improvements in quality performances in quality performance and changes in the delivery and coordination of care and finally this we certainly want to see and take the opportunity to continue testing and evolving this model in our Medicaid program because of the predictability that it offers but importantly in our other payer programs as well so if if it if it makes sense at this point i can talk about how the implementation improvement plan what its recommendations include and how they are modeling after the Medicaid experience or i can take a break yeah no i think taking a break is a good idea it's been a heavy lift it's a lot of information and i think we're we're gonna have to my the goal here today is simply understanding i mean it's not doing comparative analysis with any other health care reform initiative what we're trying to do is understand what is going on and the and the the parts that are working and then you've identified some areas for improvement i think that is absolutely key so but so i think it's a good place to maybe um switch over to the regulatory board and have uh have Elena talk about that work of there may be questions before we do that from committee members not seeing questions well i have a lot of questions i don't i don't know if i'm not good that's good i mean sure that's excellent go ahead okay so i'm i don't know we're talking about the Medicaid model and on the chart it looked like it was 80 percent of can you explain the 80 percent 80 80 roughly of Medicaid beneficiaries in the state of Vermont are attributed to the alternative payment model so there's 20 left that we could look at in the Medicaid model ostensibly that could join the aco is that i the yeah there's correct there's more there could be more Medicaid beneficiaries a full enrollment Medicaid beneficiaries attributed to the model based probably on who their primary care providers are and whether their primary care are participants in the model um i i am hedging a little bit here because i think there's also we know that when a person is duly eligible so eligible for Medicaid and Medicare that person is attributed to the Medicare program um so the Medicare program is where the where that individual would be attributed okay so for the program to work and meet its goals we're gonna have to rely on Medicare and commercial insurers and insured and everybody to join the group right correct to improve our performance in this model we need to see more participation in the commercial and the Medicare spaces okay and in the past couple of years that hasn't happened there's been incremental improvement but we have not seen the scale of participation that we see in our Medicaid program and so the loss that the aco um experienced has been absorbed by one care by the aco i i'm not sure i understand that question um there has there been well has there been a loss in in like 2019 wasn't there a loss to the system as far as i don't know whether it's reaching the goal not reaching the goal is that you know yeah i think there's a there's a difference a difference between um thinking about loss and thinking about whether or not the the ace there so for the Medicaid program i was describing that um the spending exceeded the target that's that's a question yes and so i wouldn't i don't think of that as a loss um and i would invite alina to talk about this more as well because the agreement and care board um analyzes the the budget for the aco but it i wouldn't categorize that or term that as as a loss it's it's um liability that the aco has for exceeding the the target okay thank you exceeding the payer target right so there's a there's the agreements between the aco and the payer and they have financial targets and then there's the target the 3.5 percent and the two point or you know two basis points that's the all payer and the Medicare target for the state so regardless of aco participation payment for that overage comes out of the aco to the payers yes yeah okay and really the providers yeah i'm the providers so is this the risk that we talk about yes the providers are at risk for their performance okay okay and okay we'll we'll talk about hospitals and stuff later too i'm sure thanks yeah so maybe alina can answer some of those questions i'm looking at our time alina i know we're we're going to have to come back to this because i think it is complex but it's also important to understand i i do have a question for for you um and because senator hooker uh brought it up and was talking about single payer but this doesn't obviate the potential for everyone to be covered under a single system this is this is a healthcare cost growth moderation and quality improvement model and it does not is the one care vermont is not a type of healthcare coverage and this is not a healthcare coverage model right it does seek to align how healthcare coverage works in terms of how healthcare payers pay for healthcare but it's not about covering individuals for healthcare but it also might be about how how many days you have to wait before um you get approval for a specific procedure you could have clinical alignment issues yes okay all right um alina why don't you just go right ahead and then i i know that we're going to have both of you back another time because this is a very uh this is a rich area uh and i think it's important that we understand it so go ahead alina okay and and i'm looking at our time uh we're going to have a fast stop at 10 25 it is 10 05 whatever you i think cover the things that you think are most critical for us sure and then uh we'll we will have you back okay sounds great um so you know we focused on the green mountain care boards role um just to give you some background on you know broadly in healthcare reform the board regulates certain private healthcare entities to support the state's broader goals of curbing healthcare cost growth and quality improvement um we are also the stewards of healthcare data and analytics that look across payers and across populations um in the all-payer model agreement there's kind of three key areas that we focus on so as a proxy for medicare i think inna talked a little bit about the green mountain care board's ability to um suggest um you know in in agreement with the our other co-signatories suggest some adjustments to the medicare aco initiative it um the green mountain care board also this facilitates kind of regulatory alignment between our hospital budget process our insurance rate review and kind of the goals of the all-payer model um and aco oversight certainly um and then again you know this statewide healthcare data analytics found it so as a proxy for medicare you know because the the board is the one who establishes alayna alayna i'm gonna i'm sorry to interrupt you know let's have a little um like thing up on your screen um it's blocking part of it and i think yeah there you go thanks okay no problem um so the board establishes the healthcare spending targets uh so in the medicare aco initiative on behalf of medicare um the board sets that benchmark or that threshold against which the aco is measured in which shared savings or losses so that risk component are determined um and and then we measure kind of progress towards the um towards the goals of the model we recommend and as i mentioned before the program design modifications along with our other um co-signatories so that would be something that you know the board would identify you know as iina mentioned um some of the payment mechanisms in the medicare program aren't as progressive as perhaps the medicaid program and so that could be an opportunity to work together to make some suggestions to move us in the right direction um in terms of regulatory alignment as i mentioned you know there's opportunities to make sure that um the board's other regulatory levers are working in the same direction and kind of um you know incentivizing or encouraging um participation and monitoring and and holding accountable our private um hope current um in terms of the data analytics yeah sorry to interrupt i have a terrifying question um if i may um you said that the green mountain care board is the the proxy for medicare does that mean that you essentially represent them in the all payer model and so negotiate on their behalf for this we do not we do not negotiate on their behalf i think we're we're still so after the agreement is signed i think the reason why they a lot of well all of the um state level agreements they have require boards to participate regulatory boards um and so it they sit in the shoes of medicare to ensure that the provisions um of the agreement are kind of executed and so you know i think one thing that they found interesting was vermont's rate setting authority i think maryland has a similar authority we don't use that authority right now but you know there are you know right now our authority is limited or we focus on establishing these spending targets so that healthcare system level budget um that you know is okay but if the federal government felt like there was some problem with the way medicare was participating you would be the one they would talk to and they would send us as probably as well as the other co-signatories you know a letter or notice you know as the scale target letter um came to vermont it comes to the signatories um so we're we're really you know we can go through and detail what the kind of terms are and who's responsible for what in the agreement but you know largely it's we still act as the state but the board has specific um role a specific role in establishing these targets and um kind of regulating against these targets okay thank you no problem okay um and feel free to keep chiming in i'm happy to answer questions i'm just trying to breeze through um so in our healthcare data and analytics um area you know we look at the state's performance under the model in terms of scale cost and quality and population health outcomes we monitor for rationing and cherry picking and analyze patterns and utilization and costs over time across the delivery system um so you know i just want to reiterate there's kind of these three components under the all-payer model agreement that we're that we're looking at um and so you know i think ina did a great job so i won't spend much time here on kind of the total cost of care and the 3.5 percent um it goes up to 4.3 percent before there's a triggering event um and it's that you know over the life of the agreement but there are kind of these annual assessments if you will for how we're how we're progressing um in scale you know we talked about the uh attribution process there so and you just want to remind everyone the quality and population health measures that are included in our in our agreement you know the key population health measures are improving access to primary care reducing death, suicide and drug overdose and the prevalence of morbidity and chronic disease there are then 22 quality measures underneath that either process milestones or health care delivery system quality targets that kind of align to those population health measures and these are the state's quality measures each payer has their own quality measures um that align generally with these you know these goals but they may have specific quality improvement areas that are important for their populations that they may also include in their contracting so um you know I think Ian talked about this a little bit before but we do a legal review of those payer contracts to look for alignment in accordance with the all-payer model agreement and recognizing that you know Medicaid serves a different population than Medicare than from our commercial so it may make sense for them to deviate on some measures um but we do look at those um quite closely um you know to talk about how all of these different metrics and how do they stack up against each other I think it's important to remember that the total Vermont resident spend on health care is about 6.4 billion of that you know the all-payer model total cost of care represents about 46 percent of that spend and then of that you know there's another kind of our ACO the value base or sorry the total cost of care that the ACO is managing is really 849 in 2019 849 um million that's about 13 percent of total spend and then if you look further about you know this differentiation between the value base and the fixed payments the fixed payments are really you know and this is the Medicaid um chunk that I've shown you here but there's also a little bit more in terms of the CPR program which is the primary care um capitated program that's again voluntary but you'll see that it really only is less than 2 percent of our total health care spend so you know those dollars are important for allowing um providers to really reinvest and rethink their business operations and achieve some of these goals so without increasing prospective payments it's you know we wouldn't expect to see huge deviations in delivery system you know incentives are important but having those flexible resources is probably likely to drive more more change um any questions there okay and this just shows you know the dollars and the population um you know welcome you know Medicaid may have a higher percentage um you know the dollars in total cost of care are less than that of Medicare and we know that some of our populations are sicker or require more resources so we have to look both at people episodes and dollars in utilization patterns um these next series of slides and we'll just breeze through them but basically this is to show you know of the total cost of care the regulatory control has increased over time because of this attribution but um you know there is there is still room to grow so and before the all-care model we were about um 36 percent we had regulatory control over some of the healthcare spending up to 41 percent in 2017 46 percent in 2018 and 52 percent by 19 there's still certainly 48 percent of the market that's not um where there's little to no regulatory control um another point to keep in mind you know I you know we love data we want to make sure that our our policy is informed by data but one of the biggest challenges in health care is that we rely so heavily on claims data and it just takes a really long time for the patients to incur the claims payers to pay and adjust the claims the payers to submit the data or a contractor to clean and confelitate the data and then finally we receive that data validate it and and kind of put it to work uh so you know well you know while we've you know we talked about total cost of care and and some of the questions arose where are we how are we doing um we have you know we've presented 2018 results last year and we have actually on the schedule next week to present uh 2019 total cost of care and quality and would love for you to join that if you're free next wednesday on the 31st we can send more details but at that time we'll kind of dig into a little more about what we're seeing and and you know where we think there may be opportunity um to go next um and so you know here's our reporting timeline as I mentioned the total cost of care um so we do have 2018 on our website we have the total um the quality report from and this all the scale reports there's also the public health accountability framework where ahs is the lead um we had payer differential report that we worked on collaboratively and then um you know we do have this proposal for a subsequent agreement that's due in december 2021 and so while the board um is named kind of the the liverer of this proposal it's certainly work that that all signatories are kind of um working through um together anything else you'd like to add there ena thank you that's all I had I breeze through it but I'm happy to answer any other questions from the board's perspective so um as you're talking about am I making a funny sound no okay um I I heard an echo sorry um so as you're talking about rates and uh sort of the the rate setting um authority that the board has but has not used it does bring to mind some of the issues that we were have looked at in the past and that become difficult and that is the resolution of how do you how are rates set between private and public entities so uh um payers right and how do you how do you sort of resolve the differences there right so I you know as ena mentioned medicaid sets their rates and it's through those payer contracts that providers um you know can see or negotiate their either fixed payment or their their fee for service and so through participating in the aco providers can either elect that fixed payment or they can elect to continue for that fee for service um payment whatever is negotiated with that pair uh so the aco right now is our mechanism through which these fixed payments are are negotiated so it and how do you how do you know if uh self-insured organization is it you know is is utilizing the um fee for fee for service or the value-based payments it's a good question I mean so we if we rely on their self-reporting um right now and be curious so so that is a that is a challenge is that a public is that public information um when they report it yet there is there is a public element to that okay and I think senator hardy you had a question earlier about meeting budget uh growth targets did you want to ask that one yeah I mean I think you know was getting to that toward the end of her presentation and then we switched over to Elena I mean I have I have your your slide it might be you were talking about the three point the 3.5 percent cap on growth and whether or not that's been achieved and I think Ina said to switch it over to yeah Elena so we can so we will talk about that next week what I can tell you is that um it says 3.5 to 4.3 percent uh little preview it will be 4.4 percent in 2019 um but we know that 2020 there is a significant reduction in utilization because you know we're just less likely to go get services during the pandemic so we you know we believe that over the life of the agreement it will still you know fall into those parameters but you know there's certainly opportunity um and as you know kind of highlighted and we talked about and shown in the in the graphs the fixed payment component is really so low and scale is really has been a challenge and these might be why we haven't seen the kind of reductions in growth that that we anticipated in this model but you know these are all speculative and require evaluation and further analysis well I think it's also go ahead sorry the the aggregate over the five years is also very important um because any as we're observing um certainly the pandemic highlights the the potential for some significant year to year variation um and so I think really what we what we want and why we have a five-year aggregate target is is because we want to see over the course of time moderation um and there it there can be particularly um with with healthcare spending um some some more noise in the short period be you know year over year well and last year would be the noisiest wouldn't it or the quietest depending on but yes and from the data perspective yes yeah so I have another question but senator hardy why don't you go right ahead yeah so to pair with that we're we're not quite meeting the spending percentage targets um are we meeting the population health goals and the sort of outcome goals good question who's who's good very good very good and we will excuse me we'll dig into those results next week um but you know we have seen progress in some areas and there are certainly opportunities with other and I know that's not you know they're they're 22 measures so I think it would it would behoove us to look at those in more detail to there's not just a yes we're good or no we're bad it's really you know there's always room for improvement and the data show that we have made some improvement but we should talk about where we can go next what is the thing next week and what time is it oh I'm sorry it's the board meeting the staff will be presenting the total cost of care and the quality results um for the all-pair model results for 2019 um I can send the time and details to to you all yeah chances are we're not going to be able to come but just on the off chance that we can it would be interesting to at least pop in and I believe I believe they're recorded too it's zoom and we've got a youtube recording they can go out and look at those they're kind of fun there you go but don't invite anybody else so no but but listen the sort of the question around the quality metric analysis that is done at the aco but then the assessment of whether or not targets have been reached is that done by yeah so that there there are we have a quality framework in the all-pair model and then the aco so that's not with the aco that's just between the state of vermont and medicare um and then there's the aco payer contracts that have their own quality metrics and that's what we check for alignment to the aco program and then the aco kind of sets those goals right and then has a quality improvement framework so they they're working against those payer contracts and so that alignment between the payer contracts and the state's quality framework are really what drives that but you know inna can talk to all the other work that's happening that's really about you know because this the all-pair model quality framework is not just the aco um it's all the work that's happening in vermont to really affect these outcomes so uh we we need to we need to close but i it seems to me i mean my i always i think that the work that's going on is headed in a in a visionary direction to to incorporate our designated agencies are our social service organizations are long-term care organizations i think our home visiting is just uh and having care management so that patients don't get lost in a polyglot system but it does seem to me as we listen about the quality metric analysis and and evaluation that there must be a way to simplify some of this uh because the ordinary human is going to have a hard time sorting it all out um that and then uh we've we've we've talked with the aco many times about simplifying the message so we'll be back we'll come back to this we we very much appreciate all the work that you've put in to to bring this to us you as usual you both do an exceptional job and greatly appreciate it so we'll we will come back to this the committee is all excited about it can we can we get like a little download of your brain or a chip or something so because you understand it better than anyone else we talk to so thank you both it's good so they are the experts um so we're we're gonna we need to switch off we're going to a joint assembly on um judicial retention i guess it is right good we'll get the vote back so thank you