 I'll call to order the Green Mountain Care Boards hearing of November 1st. Hope everyone had a nice Halloween. We have one substantive agenda item today. We have Lore Health ACO review. We'll have a staff introduction by Michelle Sawyer, our Health Policy Project Director. And then we'll have a presentation by the Lore Health Compliance Officer and Executive Director. So first we'll start with the Executive Director's report. Thank you Mr. Chair. So first start with some public comment periods that are open. I ask you to look at our Green Mountain Care Board website under public comments. There are several listed there right now. The Lore Health budget open public comment period is on the website as well as One Care Vermont. So please take a look at those and look at the dates that we want to have the public comments in order to be put before the board before we make a decision. I also wanted to remind everyone that we have an ongoing public comment period regarding our next potential model with the federal government. Any of the comments we receive we share those with our colleagues over at AHS, Agency of Human Services, as they are leading the negotiations on the model. And last but not least is we have an open public comment period for the community engagement work that the board is doing regarding Act 167 and hospital sustainability. So there's a link to add a public comment for anyone who may not or in addition to attending my next announcement of regarding community engagement work that the board is doing. We were asked by the legislature in 2022 to provide a very thorough community engagement process to understand the current landscape of healthcare in Vermont. It is going really well. It started about two weeks ago. There are nearly 40 meetings scheduled. There's about a third of the way in. I'm happy to report that the response from community members and providers throughout Vermont has been very robust. So I just want to encourage those on the line who live in Vermont to check out a meeting either in your community or statewide. All of these meetings are virtual for the first part of our community engagement. And it's very simple to find out when a meeting is in your area as well as how to register and sign up and attend those meetings. So thank you all for getting the word out. I'm really thrilled at the response and we're very happy to hear everyone's voice in this process. So that is all I have to comment and report out on for today. I will turn it back to you, Chair Foster. Great. Thank you. We had a meeting last October 27th. The board members had a chance to review those meeting minutes. And is there a motion to approve? So moved. And I'll second it. Is there any board discussion? All right. All those in favor of approving the minutes from October 27th please say aye. Aye. Aye. Aye. And the minutes are approved. And with that I'll turn it over to Michelle Sawyer. Thank you, Chair Foster. I'm Michelle Sawyer, Health Policy Project Director with the board. I'm here to introduce Lore Health ACO. This is the second year they have come before their board to present their budget as 2024 will be their second year in our state. All right. So let's... I'm sorry. I'm sorry. Go ahead. Okay. Let's look at this chart briefly to orient ourselves in the regulatory process as it pertains to Lore Health. On the left we have ACOs that accept payments from Medicaid or commercial insurance payers. You can see that both certification and budget review are required of these ACOs. And on the right we have ACOs that only accept payments from Medicare. Because Lore Health is a Medicare only ACO they are not subject to the certification process and are only going through the budget review. Lore Health does have fewer than 10,000 attributed lives in Vermont so the review is based upon the standards and processes that the board deems appropriate whereas larger ACOs would be subject to all standards and processes established by Rule 5. And finally as is highlighted in the bottom green box the Green Mountain Care Board has developed Medicare only guidance for these types of ACOs with fewer than 10,000 lives. And this guidance is the basis for the review. This slide outlines the budget review process as outlined in statute and rule. In deciding whether to approve or modify the proposed budget of an ACO projected to have fewer than 10,000 attributed lives in Vermont during the budget year the board will take into consideration any benchmarks established under section 5.402 of this rule. And at this time there were not any benchmarks set for the Medicare only guidance. Second those criteria listed in 18 VSA 93 82 B1 that the board deems appropriate to the ACO side and size and scope which we will discuss shortly. Three the elements of the ACOs payer specific programs and any applicable requirements of 18 VSA 95 51 or the Vermont all payer accountable care organization model agreement between the state of Vermont and CMS and for any other issues at the discretion of the board. So the staff recommend that board consider the following factors from 18 VSA 93 82 when reviewing lower health ACO budget. Information regarding utilization of healthcare services delivered by healthcare providers participating in the ACO and the effect of care models on appropriate utilization including the provision of innovative services. The character competence fiscal responsibility and soundness of the ACO and its principles. Any reports from professional review organizations. The ACO's efforts to prevent duplication of high quality services being provided efficiently and effectively by existing community-based providers in the same geographic area as well as the integration of efforts with the blueprint for health and its regional care collaboratives. We also recommend that the board consider public comment on all aspects of the ACO's costs and use and on the ACO's proposed budget. Information gathered from meetings with the ACO to review and discuss its proposed budget for the forthcoming year fiscal year. Information on the ACO's administrative costs as defined by the board. The extent to which the ACO makes its cost transparent and easy to understand so that patients are aware of the costs of healthcare services they receive. And the extent to which the ACO provides resources to primary care practices to ensure that care coordination and community services such as mental health and substance use disorder counseling that are provided by the community health teams are available to patients without imposing unreasonable burdens on primary care providers or on ACO member organizations. These factors were chosen based upon the size and scope of law health. They do have a limited presence in Vermont and they have a single network participant and a small number of Vermont lives attributed to the ACO. This slide is a reminder of the timeline for Lorehouse FY24 budget review. So today we are having the ACO's budget hearing. Later this month the Green Mountain Care Board staff will present their analysis of Lorehouse budget submission to the board and include any recommendations at this time. And there is a potential vote scheduled for December 6th. And as always the board welcomes comments from the public on their proceedings. The deadlines listed here allow the board to consider public comment ahead of each upcoming event on the timeline. First public comment can be submitted by Wednesday November 15th to be considered ahead of the staff analysis. Or second public comment can be submitted by Friday December 1st to be considered ahead of the board potential vote. And this is the agenda for today. We just reviewed the board's authority and criteria. I'll hand it over to Lore to go through their presentation. There will be time for questions from board and potentially staff. Time for healthcare advocate questions and public comment. And if necessary there is the opportunity for an executive session. So I will hand it back to you Mr. Chair and I will pull up slides for Lorehouse. Great. Thank you. I'm going to have our attorney Mr. McCracken swear in the folks who will be testifying today for Lore. Thank you Chair Foster. Mr. Atala and Dr. Brice. Sorry. Are you the only two who will be testifying for Lore today I believe? Yeah we do have outside counsel under Troy but he may not need to swear on. Typically we wouldn't swear in outside counsel unless he's providing substantive testimony. So if you two would both raise your right hands I'll go ahead and swear you in. Do you solemnly swear that the evidence you shall give relative to the cause no other consideration shall be the whole truth and nothing but the truth. So help you God. Great. Thanks very much and we will turn the presentation over to you. Thank you Mr. McCracken. Mr. Chairman and Ms. Sawyer thank you for that introduction and overview. So I'm Mark Brice Docker. I'm a primary care provider and the executive director of Lore Health ACO and it's a real pleasure to be back with the Green Mountain Care Board for a second year. We've had a really good start to the 2023 performance here. We've got such a great partnership with North Star Health down in Springfield. We were able to spend some time with the team there earlier this year and I would say it was the first opportunity I had to come to Vermont and it was a lovely visit and such a beautiful, beautiful place to come and spend a long week together. So we've also had the pleasure of through the year working with other community partners have been able to partner with some skilled nursing facilities to expand our programs for 2024 and it has some very good truthful and encouraging conversations with one of the local area agencies on aging in over the Springfield or Brattleboro areas. And so we're looking forward to our budget review today. With that I want to introduce Mr. Mark Vitala and he is going to leave that review. Over to you Mark. Thanks so much Mark. And Michelle, next slide. In terms of agenda items we wanted to go through really three main topics. So just to reorient everyone to really the Medicare SSP program quickly. I'm certainly happy to answer questions there. Talk through us and more health in the ACO and experience our timeline just to clarify what we receive and when. And then go through our Medicare only budget submission for 2024 and I'm certainly happy to answer questions here. We're in executive session if deemed appropriate by the board. So the next slide. At the highest level the Medicare Shared Savings Program was established in 2010 through statute in the ACA and it really has the intent to promote accountability for the fever service Medicare population. And so prior to both whether it's the CMS Innovation Center or which you have an all-pair model through or the authority granting the statute, Medicare fever service beneficiaries really sought care how they did and it was really up to those providers to ensure that patients were cared for and coordinated. And so through the Shared Savings Program, Medicare is attempting to really formalize that accountability through an accountable care organization to coordinate item and services really in a part A and B. So part D is not which is drugs is not included and then also ensure that there's some longer term sustainability through infrastructure and hopefully redesigned care processes. So hopefully fully aligned with the GMCB's mission and name. That was the statutory duration. The federal regulations are under CFR part 425 and so there's a suite of things that really all ACOs must comply with there and that's really what establishes what Medicare SSP ACO follows. With that I've noted about the regulation but then elsewhere SSP ACOs must comply with all applicable laws, Federal Criminal Law, False Claims Act, Antiquity By Statute, CMP Law, and then Physician and Self-Referral Law. And so given that the program is over a decade old, the program is delivering savings both for the trust funds and then really federal taxpayers. And so last year, and pretty consistent with previous performance years, overall saved around $1.8 billion for the Medicare trust funds. Next slide please. And so for how does CMS manage any ACO? So first there's an annual applications cycle. We do go through the applications cycle every year. There's different questions that are asked really for a first initial applicant versus what we can change annually. And so the first review is really for what we went through last year and the last time we met we had not actually gotten approval and since then we have got approval so we're live for 2023. And so that is a five-year agreement period and we're in the enhanced track of the shared savings program. And so as part of any shared savings program in ACO, CMS requires that we establish a shared governance and so that shared governance is predominantly led by the ACO participants themselves so they control 75% of our governing body and then in the case that there's an ACO and a two-sided risk track so both up and down side risk, which we are, Medicare SSP ACOs have to establish a repayment mechanism before even getting a participation agreement from CMS and we have done that and CMS sets with that financial guarantee or that repayment mechanism is either a surety bond, letter of credit or dollars in escrow and the CMS tells the ACO what that amount is annually there. And so as an ACO participating both now and then in 2024 we satisfied really all these federal requirements that we've outlined. Okay so moving on really to our participation in Vermont so we have one ACO participant in Vermont and so the term ACO participant it's the term CMS uses so the shared savings program operates at a tax ID level so a 10 level and so all providers that bill Medicare under that 10 and that are considered part of that ACO participant and so as part of that there's around 3,800 Medicare fee reserves of beneficiaries that are attributed to that 10 and so that ACO participant. Two of the providers at that ACO participant are part of the ACO's governing body. What that really entails is that they have a fiduciary duty to the ACO including really the responsibility for oversight and strategic direction of the ACO and then holding ACO leadership and management accountable that the ACO accomplishes the goals set up by CMS. I'm sure there's a question. And then one question that I think we've received was a little bit more detail on our participant in Vermont and their commitment to lifestyle medicine so our Vermont participant has actually two boarded diplomats of lifestyle medicine through the College of Lifestyle Medicine and the American Board of Lifestyle Medicine and so how they really work to promote lifestyle medicine is they have both a constitutive model where there's one-on-one appointments with them, share medical appointments with a broader group of patients and then classes that people can people can join and then secondly really a distributive model where they're training other providers on the core pillars of lifestyle medicine and those providers, well they may not want to go down the path of getting boarded, they're still exposed to what the core pillars of lifestyle medicine are. And Mark, Dr. Brie Sacher, is actually at the annual conference now so we have the pleasure of meeting a few people from Vermont there. Okay, next slide please. Was there one before this? There you go, thanks. So in terms of our experience with SSP and to think through our timeline for budget reviews, we just wanted to give a little bit of what do we receive and how does that work? So January 2023 is when we started our agreement with CMS. We get a set of data every month that really is claims information. So that's one that we process but really the crux of what we receive is done quarterly and so quarterly we receive a set of reports that says here's the beneficiaries that are attributed to you and so we've elected as an ACO to make sure that the beneficiaries that are part of the ACO are actually receiving care from our ACO participants. And so what that looks like is we get an initial list of beneficiaries who are receiving the plurality of their primary care from our ACO participants, in this case our Vermont ACO participant. And that changes over time, those beneficiaries can be added, they can be removed. And so we receive that really every quarter. And then with those quarterly reports we also receive for that full set of new, really the new set of beneficiaries, again most of which are old or have been attributed just previously, some of which are new, a sense of what their actual expenditures were for that previous 12 months. And so that previous 12 months starts rolling. And so as you can imagine, given claims lag and other pieces that we're sure you see in other parts of your regulatory experience, we receive really reports starting around April for 2023 and then and actually after the performance year. And so just from a understanding what do we have as of today even, we really have data through from these quarterly reports really through June. And so we're hopeful for more data this month but that's just the general cycle for the board. Next year we'll submit quality data to CMS. So CMS has a set of, we are a, as part of an advanced alternative payment model, we are actually a qualified, our providers have hit a qualifying participant status in the QPP program. And so they're exempt from MIPS but the ACO reports quality metrics on their behalf. And so as part of that we'll submit our 2023 data at the beginning of next year based on CMS requirements there. Then we expect for the 2023 year, so risk scores are not final until generally the very end of Q2. And so CMS will give us our ACO results both for quality and cost in 2020 around July or August of 2024. And so that's the general timeline that we operate under and hopefully that provides some good color for the board of why we either do or don't have certain questions that you may maybe thinking about. Okay, so next slide please. And similar to what we shared last year, so shared governance. So we have 75% of our voting is held by ACO participants. 25% is by beneficiaries, consumer advocates, or the ACO leadership. For how we are assigned beneficiaries, so again it's because those patients as beneficiaries are getting care from a specific TIN, that care is they're getting the most of their primary care from that TIN, or they've chosen to voluntarily align themselves with a TIN or provider. And that change is quarterly. So we'll receive a final list actually after the year, but we're caring for everyone that we're currently aware as part of the ACO. For 2024 we are adding a new waiver. And so we haven't, CMS has not given final approval on this, they'll do that at the end of their second phase of applications. The SNFs themselves have been approved. So we have two SNFs in Rutland, and so they've, if we do have waiver approval, there'll be our skilled nursing facility affiliates for the skilled nursing facility three-day rule, which allows patients to not have access to the Medicare benefit for skilled nursing facility without having a three-day stay, three-day inpatient stay. For our risk model, we're a part of the enhanced track as I mentioned. And then we've established a minimum savings or loss rate of half a percent that's consistent with last year. And then last slide. So the way that we think through our general financials, and I'm happy to work through this with everybody. So in Vermont, we expect this to be around 3,800 beneficiaries. As we annualize that, not purely 12 months, people pass away. So we use a little bit of a factor there, but you can think about it as 12 months. So we tie that into essentially member months. And so there's about 44,000. When we go through where our patients are and their expected costs plus expected trending increases from CMS for 2024, we're expecting around $9,900 benchmark per person annually. And so our expectations in terms of benchmark, and so this may be a little bit of a change from how to think about it. So CMS will set really the benchmark to say what should your expenditure have been for 2024. And that's our assumption on benchmark. And so then from there, we'll either achieve some savings or some losses. And certainly we don't know where that will head. And then the way that we'll either aim on it or receive money from CMS, if we receive savings, so it'll be the percent of shared savings. So that'll be a TBD in 2024. Times our benchmarks, so benchmark 36 billion, 36.5 million, it'll be the shared savings percent time that we'll also have a quality performing score. And then CMS keeps 25% and they share 75% with the ACO. And so the ACO in the current enhanced track doesn't receive all the savings, CMS keeps the proportion. There's losses, very similar formula, but based on the quality performance score, the ACO may only pay 40% of those losses and there's caps there. Just to give you a little bit of a sense of 2022 results, there's about 480 ACOs in 2022, as I mentioned earlier, the $1.8 billion of those ACOs and the average savings was around 3.8%. And for the ACOs that had savings, so 4.8%. So the majority of ACOs, I think it's around 85% achieved savings. So just in terms of the model, it seems to be successful in driving improved utilization broadly. So happy to answer questions and have a dialogue. Great, thank you both. Ms. Sawyer, did you have any questions that you wanted to start with or did you just want the board to go first? I do have a few questions, if you don't mind, Chair Foster. We had sent Lore Health a series of questions in response to their budget submission and there were just a couple that I was hoping to get a little bit more clarification on. Around, we had sent a list of quality metrics. It was an appendix D, which for the public, the guidance is available on our website if you wish to reference it. And we had asked Lore Health for their feedback about the feasibility of potentially reporting on those metrics and you all had responded by recommending aligning our reporting with that of CMS, which we understand. However, we were curious about if it was to be requested by the Green Mountain Care Board. Does the ACO have the ability to report Vermont-specific results for any or all of those metrics in appendix D given whatever CMS is sending to you as far as data goes? We're curious about hearing what steps would be necessary in order for Lore Health to be able to report those performance on those metrics. That's a good question. So I think if I just to repeat back the question, it's helpful to know CMS already providing us with that information. Could we then parse it out specifically to Vermont? Or would it be a set of administrative analytics, et cetera, from data that we have to pull from? Is that fair? Correct. I think it would be helpful to know how much of both a burden it potentially could be or if it is not a huge lift for you all. Yeah, we totally appreciate the question. So if we had received this data from CMS, and we certainly received a lot of data, it's not data that I'm aware that we receive. And so we can do analytics to get to the metrics that you've requested, especially around the ambulatory sensitive emissions. And so I think we're certainly able to do that through analytics. It may require us to hire an outside contractor to help us get there. But we're certainly able to, if it's the board requested, we'd like to meet your request. But it's not data that I'm aware that we received from CMS today. Okay, so potentially what they send you after the end of the program year might allow for that data to be analyzed? I don't think so. So I think what we receive from CMS really is claims data, and we receive data that shows us our utilization. There's not a breakdown of potentially avoidable emissions by all the disease states mentioned. That being said, the areas that we've looked at. And so we feel like we can get you the information. It's not data that shows directly from CMS that we could say this is Vermont section, and then here's what that looks like. But I think we could get there if it's something that the board really is tracking. It would just cost us dollars in time. Maybe Ms. Sawyer, what I would add is we are just to maybe reinforce what Mark said was that we'd be interested in receiving what the measures are that you're and then having a conversation about what's possible and really focusing on what's the objective or the goal of that information and what insights are you looking for? Because that request might be the best way to provide that. Maybe there's another view or another analysis of performance that would also answer that question. So we would be open to having that conversation. Sure, great. Thank you. Oh, that's very helpful insight. Great. I also, I had a question about just your model of care. I was curious if you could speak to how much care coordination plays a role in your model. And if it is a pillar of lower health, is there a way that your ACO promotes its practice and its network of providers? And if it is, do you track rates of care coordination in any way? Mark, do you want me to take that? Mark, oh, happy to come behind. Yes. So we do provide a report to each of our ACO participant groups that gives them information on which beneficiaries are, have been in the hospital, which have been in the emergency department, what conditions they have, what medications they are on. And then we meet with each of our, we meet with our North Star Health every two weeks to have, it's essentially a operations coordination call. And we present the information to them. And given the claims, the data leg that Mr. Attala shared earlier, this is a process that has just started up. And we've had our, we had our first call and it was well received. With respect to, do we track coordination events? No, we don't do that. We do, we 100% agree with, and we are always curious about, we agree with the idea and we are curious about how and understand what are the care management functions and capability of each of our partners. And in fact, you know, when I was in Springfield, I had a chance to meet with that team when earlier this year. And I can tell you that it's something that's really important to each of our partners as well. But we don't actually track those events. The, I would say the ultimate outcome that we are looking for is better health of Vermont Medicare beneficiaries, a better understanding of when to access the right care at the right time. And ideally over time, we will see a decreased utilization of the emergency department and a decrease in primary acute admissions. That's how we'll know if all the care coordination that's both happening at the partner level and then the, and then our work in terms of supporting them with data and actionable things to actions to take is making a difference. Just one, one additional point too. So as we mentioned with the two skill nursing facilities, we're hopefully bringing online the CMS approves our application. So we'll have, you know, kickoff and coordination calls there to say, you know, here this waiver is now available for this set of beneficiaries. And so what our hope there is that we work with discharge planners or emergency room or even before that to make sure that people are aware that you don't need it in patient's day. You don't need to stay for three days to, if you do, if you need the additional level of care that a skill nursing facility could provide. So I think that's the other piece. So we, you know, we certainly track that that is data that CMS provides us. Essentially over the last year, how many times has market hall been in the ER? How many times have I had an inpatient admission? Then where are my, you know, blood home health agencies am I using what skill nursing facilities am I using and such so that we're hopeful that that's an impactful addition for 2024. And Michelle, does that help answer? It does. Thank you both. And I have no further questions. I'll hand it back to you, Chair Foster. Thank you. Great. Thank you. I'll open it up to the board members for any questions or comments they may have. Member Lunge, I see you unmuted. Yes, I have a couple, but I was waiting to see if Dave wanted to go first. I think it was close, but I'm going to call it, I'm going to call in favor of Member Lunge. I think she was first. Okay. It was close. It was close, Dave. Well, thank you. I'm quick on the unmute button, I guess. Hi, all. Thanks for joining us today. I had a couple questions about the three-day SNF waiver and what you're, you've mentioned a little bit about what you're thinking about in terms of implementation. I was curious how slash why you picked two SNFs in Rutland, which is an hour and over a mountain range from Springfield. So I was just curious about that choice and how usable that would be given sort of the geography here. Yeah. I mean, thank you for the question, Ms. Lunge. One of the requirements of skilled nursing facilities to participate in the waiver is they have to be rated at three star or higher. So we start with that list. And I mean, in the ideal world, every SNF would be a three, four or five star SNF, and we would be able to have a broader coverage. When we realized what the options were, oh, and then of course, we reached out to all the skilled nursing facilities and got great assistance from North Star Health and making introductions. There are also varying levels of interest in participating, so that decreases as well. In the end, the decision point was, do we go ahead and get started, even though it's not the ideal, so that we can learn and we can get the right operational processes in place? Or do we wait a year? And we obviously decided, let's just go forward and learn. And an objective for 2024 is to continue to have conversations with other skilled nursing facilities. And then we'll actually be able to show them that we do have some who have already started, so they won't have that. I'm not sure if I want to go first or not type of a decision point. And then we can expand it. And I hope to report back to you in a year's time that we now have even more skilled nursing facilities joined. And if we can make a plug, I mean, there's not a change. So in terms of what the waiver means, it means that when they submit their claim to Medicare, they essentially add a payment modifier that says, we understand that this patient doesn't have a three-day qualifying stay, but they're part of the ACO. We've checked. There's a whole set of things that needs to verify that the person deserves or needs SNF care, et cetera, and that it's appropriate for them. And so I think from that end, in this case, we're part of it with partnerships with North Star, and it's part of that clear coordination of where do they already know some of their patients live and then where it may care be tougher to get to. And so you can avoid an ER visit and go straight to a SNF that's nearby. That may be an ideal scenario for some patients, but certainly we'd welcome other skilled nursing facilities that want access to the waiver to reach out to them. Thank you. I was also wondering if you could provide a little, some examples about the in-kind incentives that you offer to beneficiaries, just to give us like a sense of what kinds of, what types of things are we talking about here? Be happy to do that. So the in-kind incentives that we offer are the types of things that just help people understand how they're doing on their own personal health journey. And so there's a couple of home-based tests. I'll give you one example. So chronic kidney disease is a really important health topic. It is underdiagnosed, so a lot of people walk around with the early stages of chronic kidney disease, but they don't feel sick, they feel just fine, and they don't even know that their kidneys have started to not work as well as they should. So we offer a home-based test where they can administer itself. It's an FDA-approved test. We have a great partner that provides that, and they then can find out themselves, and if it's normal, they know right away. If it's abnormal or highly abnormal, which are the three results that the test provides to them, they are then encouraged through the app to go ahead and reach out to their primary care provider. We get a report of the results, and if we have permission from the patient to contact their providers, we always check that from a privacy perspective. When we get the result, we then reach out to North Star and let them know that one of their patients had an abnormal result. Here today, almost 50% of our Medicare beneficiaries who have done this test have had an abnormal result. I just got to say, even if we have one person this year who understood that they have kidney disease and got in with their clinical team and got on the right therapies that can prevent the progression of disease, and even maybe this was their moment to say, I'm going to change my lifestyle and I'm going to start walking more and I'm going to eat a little bit better, I'm going to think about my sleep, I'm going to think about and work on the, so that I have a normal, healthy amount of stress in my life. If this was the event that made that happen, then we have accomplished so much in that moment, so that's one example of the in-kind incentives. Just broadly, the in-kind incentive, just as a reminder, for us, it has to be something that's not covered under Medicare, so if it's something that's a covered benefit, we can't offer it an in-kind incentive. There are items that are related to the person's health and then, again, not covered. If the board chooses a negative session, we're happy to offer additional details that desire. I have a bit of a technical question, so I'll ask it and you can let me know if it's too technical. I was curious about the CMS HCC risk adjustment and what you think about that methodology. If you're finding that risk adjustment methodology to be representative of the population, I think there's been some criticism of that methodology in areas with access issues, for example. I was curious if you've dug into that to see if that methodology in the shared savings program is working for you. Yeah, I'll offer you probably maybe a different answer than you'd initially hope for. So they proposed actually a new model for 2024. They're phasing that model in over three years in Medicare Advantage. It's been a proposed rule for this year that has not, that rule has not been finalized, so we're actually not sure which approach CMS will take in terms of HCC scores and HCC, just for others, the public, the hierarchical condition categories. So the way to try to take into account the conditions that a person, a provider, that the person has to their spending. And so there'll be a standard spend and then multiply by the risk score to give what their spend should be for the year. And so I think from, generally, I think criticisms of the HCC score, they work very well around the middle, and they don't work very well on the two tails. I think the considerations to think through broadly, and I wouldn't give anything, is some providers, so for example, an FQHC doesn't bill a Part B claim, they bill a Part A claim, and so they may be less adept at submitting diagnosis claims because a Part B claim captures, I think, up to 10 HCCs. In the case of an FQHC, their payment may not be different, and there was a different either. In either case, the way they submit the claim doesn't really lend itself to submitting HCCs. And so you can read into that. Would you find some providers, potentially, the record that they've submitted doesn't match what the actual QD of the patient is, which means that in theory, the pay us as an ACO looks potentially worse than the reality. And so I think those are all parts that could exist. And I think the way that we think about it is we're not the provider, and so unfortunately, we're not able to decode. And so I think we're very supportive of a complete medical record, an accurate medical record. I think the model itself, we'd reserve judgment and leave that to the health economists at CMS and a lot of others in the industry to get to opine on. I don't think our model, we're living in the model. So if it works, it's great. If it doesn't work, we don't have it. We can request a change, though. But I'm not really in our control. Does that hopefully that gave you maybe more than you want? Nope, that's great. I think that's all I have for now. I may have lost one question, but I'll turn it over to Dave and let you know if I found anything else. Thanks. Yeah, thanks. I just wanted to sort of expand a little bit on the sniff engagement you mentioned in the opening remarks that you were partnering with skilled nursing facilities. Is this partnership in relation to the three-day waiver, is that, are there other layers of the partnership? It is in relation to the three-day waiver. There are parts of that part of the regulation where there are some operational things that we will work on, focus on obviously on coordination and knowledge of who, which beneficiaries are under ACO and then there's some other just some standards to meet in terms of communication and coordination. And so we certainly, that's the purpose of the upcoming coordination calls is to begin to work with them on those things. Okay. Are there any incentives for skilled nursing facilities to partake in the three-day waiver or more with you, you as an ACO? Well, I think the, if I were to put myself as the medical director or the operations leader of a skilled nursing facility, the incentive that I would see is I can partner with a value-based care-oriented organization in more health ACO who is caring for 3,800 and partnering in care of 3,800 Vermont beneficiaries. And to the extent that those beneficiaries, if they get to a point where they need to have additional support through the services I provide, that those beneficiaries are going to be directed to me because I, because they do not have to be admitted to the hospital for three days before that admission occurring. And so that would be the kind of, I think the business imperative and opportunity that I would see about SNP operator. They then, they of course still go ahead and submit their bills for the, you know, the bed charges and all the services that they provide to CMS just as they would normally do. That's all I have at this time here for my fellow colleagues. I don't have any questions myself. Member Holmes? Yeah, just one, a couple, maybe two quick questions. One is, you know, you do talk about a focus on health equity in your narrative. And I'm wondering if you've been starting to measure or collected any data on the uptake of these in-kind incentives by socioeconomic status, you know, any evidence that these in-kind incentives are going to have potential to close the health equity gaps? Yeah, I mean, I think, I think broadly the way we've thought through that is really by the partner we have and the general population that would receive care and FQHC may not, you know, doesn't reflect the, reflects the population that may have greater socioeconomic needs than other providers. And so from that end, one thing we've focused on is, and you know, we're going to have to or choose to enter into the next session. You know, we've looked at what are the, what are areas that could be meaningful to a person to address health equity gaps? And how do we help in ways that the general Medicare benefit just cannot or does not today? And so that's, that's been how we've thought through it. In terms of, in terms of uptake, I think we've seen a pretty consistent uptake across the population, but not to nothing stands out in terms of, you know, how we made to find a lower socioeconomic status, beneficiary versus non. And Ms. Holmes, first of all, thank you for asking that question. It's important to us, that's why we included it in the narrative. And we're early, you know, we're very early in terms of being able to measure so many things. And in fact, the clinical team that I lead is working on, you know, what are the, the proof points of from a health outcomes perspective that we want to be sharing in about a year's time when we have had a lot, both more experience and more participation, as well as more time to begin to actually have enough to do these types of analyses. So your question actually is timely that it helps us add this to what are the things that we should be looking at. And so thank you for asking. Well, I look forward to seeing, you know, maybe that this time next year, we'll have more information on that as you're thinking about the design. I guess my other question is around, you know, the narrative described no real plans for expansion in Vermont. And I'm curious as to why, to some degree, and it seems like there are, you know, an economist. So I'm going to say this economy is a scale to achieving scale, literally, or to expanding. So I'm wondering, you know, you're in four different states. Why not focus on one state and expand within one state? So we would love to. And in fact, we had earlier this year, we've had conversations with another provider in Vermont, as they were contemplating joining an accountable care organization. And it would be my preference to be reporting that we've added another partner in Vermont today. So we are very open to speaking with anyone to grow, to be able to partner with more organizations and serve them. I think, I think even in terms of what I had shared in terms of our outreach to the area aging, area agency on aging, as well as the SNF conversation is an example of our intent to work broadly within the community. Because that's, that's where people, you know, live, learn, work, play free. And that's where, you know, we want to be connected to the right people in all the right ways. So again, maybe next year, we can report that we've had growth in that area. Because we certainly, in fact, even today, yesterday at the American College of Lifestyle Medicine conference where I met, I spoke with a provider in Vermont who, we actually spent 30 minutes together talking about what, what lower is. And I was curious about what she does and her type of practice learned a lot. And we're going to have a follow-up conversation based on that. So if you just to put the hat on of one of those providers or a provider in the state of Vermont that you, what would you say would be an obstacle to joining law from their perspective? Or what would be a barrier? Why not jump in? Yeah. Yeah. Just, just to clarify really so that that wasn't changed in our narrative response. I think the question itself, you know, asks, do you have active plans to expand in Vermont? And our, you know, I think our response this year was we do not have an active campaign in Vermont, but we are open to partnering. So I, just to, just to add additional context. So I think, yeah, sorry, Mark. Go ahead. Yeah, no, thank you for that. The, I think that, I think that really there's, the main barrier is time and space to actually think about doing something differently. I mean, everyone's working so hard. And this is true of so many conversations we have across the country. Potential partners. And so it's time and we're on the list of their most compelling priorities with this type of work and decision-making process fall. And so we are, we are undeterred by that. We, we have those conversations. We, we stay in touch and, and we get what we consistently get our answers like not now, but come back in six months and let's talk again. And so I think it's both the reflection of, of time and waiting for maybe for us to have a little more experience so that they can, can see us doing the things we said we're going to do. And I think, I think value has been tougher for some providers to move into. I think from from our end, you know, we, we've, we handle really most of the administration of the ACO, right? So, so from a provider perspective, I think the things that they should be considering is, you know, how difficult is it to understand the contract I'm entering into? How difficult is it, you know, what's required of me? What are the financial risks either is there downside risk to me? Upside risk, well, like those types of questions and again, the broken record, happy to talk to them in a regular session. You know, they, they, those are the things that from the provider and I think they should think through, which is Mark's exact point, which is a prioritization piece. I think as QPP and additional financial sticks start entering the fee-reservice program, I think providers will be more and more incentive to actually say, I can't even join some kind of model for my fee-reservice beneficiaries. And so I think from that end, you know, I think we're an attractive option. Mark, will you just abuse QPP a couple of times? Will you just tell them what the acronym stands for? Yeah, sure. It's a quality payment program. So it's how, how does CMS manage from a fee-reservice beneficiary perspective quality for those patients? Thanks, Mark. Thank you very much. Um, is the, is the app, do you consider the app an in-kind incentive? It is not kind of in-kind of Medicare. It is a financial service for their health. So, so yes. Okay. Any questions from the health care advocate? Yes. Good afternoon. Um, Sam Pish was a health care advocate. Can folks hear me? Okay. Okay. Great. I just wanted to first thank Michelle and Russ at the board for all the work you guys have been doing on this. First couple of questions are follow-ups based on your responses to written pre-hearing questions. The first one, in response to a question about whether LOR is expanding community-based provider capacity and, you know, avoiding duplication of existing services, you said that, quote, the ACO participant maintains relationships with access navigators and others in the community to add resources for Vermont beneficiaries to understand how better to access care. I'm curious what you mean by resources, what resources are being added for Vermont beneficiaries? Yeah. So, right. That's a good question. Um, thanks for that. So, so from, from that, from our end, uh, we, again, provide to our ACOs and ACO participant, um, information on where their patients and where their patients are getting care. And so they can now AC patient acts, or a lot of patients use this set of, this care network, etc. So in terms of resources, they now have access to a set of data that they didn't have without the ACO. Um, so it's, it's one, they could have some, some, some, uh, information through your HIE, but, um, that may be limited. Uh, I think from a, uh, financial perspective, if the financial arrangement between us and our ACO participant is positive for that ACO participant, then they now have additional dollars to, uh, to care, uh, and establish a restructure, uh, on site in Vermont. So that, that's the, hopefully, uh, only clarifies resource perspective. Yeah, thanks. That's helpful. I mean, I spent some time reading about Loar's rewards and like the Loar dollars, and it wasn't clear to me like how those could be spent. Yeah, we may, we, yeah, we may, we, yeah, we may want to, yeah, that made it, I'm not sure where that was, and we may talk through that separately. Okay. It was just on the website. Um, I'm wondering if, if Loar believes at a high level that a central problem for patients in Vermont is that they don't know how to access care, because I mean, when they, in that response, you say to add resources for Vermont beneficiaries to understand how better to access care, could you just elaborate on what you mean by that? Um, I don't think there's a presumption that says they don't have access care. I think the better access care is, is do I have access to my provider? And does that provider have enough, you know, are they adding, are they adding providers into the, into their staff? Or is it, you know, a six month wait to get, to get to be seen? And so from a, so I don't think I wouldn't read, our response was not meant to indicate that. So I apologize if that was your, that was your take on. Oh, that's okay. That's the importance of clarifying and asking. So I appreciate it. Another response that you gave, as you said, by virtue of being an ACO, both the ACO and our provider partner are incentivized, this is similar to member home's question around health equity. You said there are incentivized to bridge access and care equity gaps in the population. Patients can access items and services to narrow health equity gaps. I'm curious about the, by virtue of being an ACO element, I'm wondering how you feel like by definition, that means the law is able to bridge access and care equity gap. Yeah, I mean, that one is actually by, by statute even, so in regulation. So the entire, I mean, the entire purpose of an ACO is to say, you now have a set of, providers and us that are now accountable for both the care of those beneficiaries and costs and utilization and then also the quality of that care. So, if the ACO does not deliver both improved quality or there is at least maintained quality and then reduce costs, the ACO doesn't sustain. And so by the entire program is meant to be, makes them accountable for the set of fee-for-threat beneficiaries that otherwise, you know, it's simply seed care and, you know, other than in a non-systemic way, you know, wouldn't necessarily have access to the things that ideally any ACO participant in Vermont or elsewhere is trying to do. So it is the program, I mean, that is a value-based care program. So I don't, yeah, I mean, we'll stick by the answer. It is, that is, I mean, that's the definition, that is the statutory like point of having this law to allow entities to help improve utilization and quality for fee-for-threat beneficiaries. So that is the program. Yeah, I know if I understand the definition, for me, I would draw a distinction between what the definition of something is and I guess what I'm trying to get at is how does the value-based care arrangement that you're talking about advance health equity, how does it, because simply by definition being something is different than causing or, you know, instigating an impact on something else, in my view. Yeah, sure. I mean, I think we've aligned incentives and so in the case of any beneficiary that, you know, to the extent possible that there are equity gaps, with an ACO should, you know, it's hard for me to imagine a case that with an ACO is worse than without an ACO. And so I, you know, that's just the view that, you know, I think we take in previous roles I've taken from a CMS perspective. I'm just curious how you about like make that value assessment, like how are you measuring like defining success relative to not being in an ACO relationship? I may be missing a question. Mark, I don't know if you want to. Well, yeah, let me let me see if I can take a swing at this. I think the so first of all, the fact that we have to think it's very important that our interventions work for as many people as possible. And going all the way back several years, you know, the initial initial ideas were piloted with our FQH federally qualified health center partner in San Diego County, because we wanted to make sure that that the approaches we were taking work for almost everybody. So it's so that we have three federally qualified health centers ACO overall. And it is our intent, and maybe linking to the question that Jessica has earlier, it's our intent to understand from a proof points perspective. We want to prove that this does work for as many people as possible in all circumstances that they face. And so the fact that we have additional, just as one example, the fact that we have additional information about how Vermont Medicare beneficiaries are accessing acute care services to be able to get on the phone then with the leadership team at North Star and say, hey, let's look at our list of beneficiaries who have been in the emergency department three or more times. We actually do that, you know, from my perspective, it's like we want to reach out to every one of those people. So I guess, Sam, my assumption is there is we're reaching out to the broad swath of Vermonters who are on service Medicare, and we're going to help them with their clinical team partners identify the things that are leading them to end up in the ER as often as they are. And we want to fix that form. So we will, you know, based on the data that we have access to that we receive, we will, you know, we will get to reach a point where we've done this for long enough. I think we have enough experiences where we can begin to look at it from any number of demographic factors to understand that there is a disparity in results that we're seeing. And then we can have a conversation about why do we think that's happening and frankly include the Medicare beneficiary in that conversation so that we have their perspective as well. Does that help a little bit? Yep. No, thank you. I appreciate it. I'm wondering if it's possible to put up the redacted dependencies because that is a kind of high level question about the changes in financial performance. Yeah. So we've submitted, we've actually submitted another, I mean, I'm not sure Michelle or Russ, how do you like to handle that? Because we've actually submitted a second request based on further information we've understood process-wise. I'll just note that we pulled down the original redacted version you sent us when you sent us the new confidentiality request. So we will need to receive an updated redacted version of that so we can repost that to the website. Sure. I may have a new question. Questions when I'm here? It may be. If the board chooses. Okay. I don't exactly. Yeah, go ahead. Sam, is there a way to ask it without executive session or do you need executive session to ask the question? I mean, I'd love to ask it in the public session. I mean, the request just came in recently. So I mean, I'm not a lawyer. I'm not at liberty to really opine on whether or not it's fair game. I mean, I was mostly curious about changes. Yeah, we can maybe. So if you have like a broad question, the broad question is why would our projections change over time? We can answer that and see if that meets your question publicly. So certainly we submitted a budget last year to the board. We submitted also a re-re-submission in March, April of this year just based on initial uptake. So we now have actual experience. And so I think what we're able to see how many patients are able to actually to join lower, how many patients are utilizing different parts of us and what we offer. And so I think from that end, we're actually, we're now giving you projections based off of real world experience. And so that's when you see, we see what's changed in our submission. It really is a, it's just a reflection of, we gave you our best guess last year based on our experience and we hadn't implemented, we began implementing really January this year. And we've seen, we've learned from that. And so I think from our end, where we're really encouraged is, I think our partners now, they've developed momentum. And so that their providers understand what the ACO is, they understand what the program is and what additional incentives available to their patients are. And so now they're able to have those conversations. And we're seeing really what we hope for, which is a pretty substantial increase in patient engagement and uptake. So I think from that end, we're encouraged there. And so I think what you see in the broad submission is our assumptions around what we think are better assumptions based on our current directories of what 2024 should look like. So I think from that end, we're still, that's what we're tracking to, but I don't know if that's sufficient. And Mark, feel free to add from behind, please. Okay. I had a couple of questions. The last thing about beneficiaries access to the platform and whether or not you track that, would Laura prefer to answer that in public, or is that more of an executive session question? We do not track that. We track, every beneficiary has a choice to join Laura. So that's their choice. So we, the parts that we track are who's actually joined. And then from that end, it's their choice, it's their preference that they choose, they choose both to join and they choose to continue to find value in working through different parts of their health and part with us and part with their providers. Okay. Do you feel like the app is the primary mechanism by which Laura hopes to make inroads, improvements in quality health outcomes, that sort of thing? Is that like a major vehicle or is that just a part of the care model? Yeah. I think we meet people where they are. So if they're able to engage in the app and join a community of people, that's certainly our preferred path. They still keep their relationship with their providers and that's standard. And so we hope that that is enriched. And we really are just sitting beside that. I think for people that are non-digital, their digital health literacy maybe, or access maybe limited to non-existent, we have accommodation and accessibility pathways that we work with them on. And so I think from that end, our general view is that people that are thinking about how their decisions and how they're learning about how their health is impacted from diet, exercise, sleep, go down the list, stress, I think the question commonly is childhood trauma and how that impacts over time, someone's health. So we look at that as product chronic or systemic inflammation that has sequelae and disease. I think all of that is a focus of the broad approach that we take. And I think that the way, the medium that that's affected by or affected in is a combination. Sometimes people will join the digital community. Sometimes people will do that in a non-digital way that is more of them and reflections on their own engagement with the things that we help provide them. Okay, thank you. Those are all my questions. Appreciate it. Thank you. I'll open it up to public comment via the raise the hand function. Alter, did you have anything? I saw you appear here. Thanks, all. And yeah, you've got me pegged. Most of my questions, the board and Sam have already asked, but I was concerned about a couple of things with this lower health. Are you one of them is transparency? Are you or are you not a direct contracting agency private equity firm? Second to that is exactly where are you headquartered? And this picks up off of Jessica's question. Third, is there a way, can we, can we, can we by chance answer each question? Just, I won't remember them. I want to make sure we answer each. Is that okay? Okay. Go for it. I think your first question is, oh, sorry. Where are you headquartered? The ACO is headquartered in California, San Diego. I saw a list on the web that said you were in Hong Kong. We are not in Hong Kong. That was Gatter Health, which is formally your parent. They're maybe. Sorry, let me interrupt. Let me do it this way. Walter, why don't you go ahead with any comments or questions you may have and then I'll see if there's any that I want to pass along to the folks from Laura. Yeah, that might work a little better. And when we say transparency, profit and loss statements, what are the CEOs compensated? Because this is obviously a managed care type thing for lack of a better phrase right now. Do you or do you not deny claims? And I ask this too because my Medicare prices are almost doubling next year. And when you say beneficiaries, I wonder if we really are a beneficiary because we're being forced by the federal government to pay this. And this is another middle person within the doctor-patient-medicare relationship. So I'll leave it to Owen. But the transparency is, as a patient, the transparency is the one I'm looking at. Can I maybe answer one question, Chair Foster, and then just to clarify? Mr. Carpenter, so just to orient, so we are not a managed care organization. So that would be in the context of Medicare, generally what's called the Medicare Advantage Plan. So we are not a Medicare Advantage Plan. And so go ahead. So we do not have the ability to deny claims. We don't have the ability. There's no network. So someone who is entitled to Medicare that are beneficiary of Medicare has the option every year to choose a private plan administered through Medicare Advantage. They have the option to remain in fee-for-service. We're not in the middle there at all. The middle there is, presumably, you have a relationship with your provider. We partner with providers, broadly. And then if you're a patient of that provider and that's who you receive your primary care services from, we can only do things that are additive to try to help you be healthier. But you can choose not to engage with them. You can still maintain your relationship with your provider, but Medicare is your coverage if you're in fee-for-service, which it sounds like you might be. As of your fee-for-service, if your Part B premium is going up, that's in regards to just general cost inflation and health care. And I think the Green Mountain Care Board is trying its best to address inflation in Vermont. But sometimes there are things that are federally based in terms of price increases from actuaries. So new drugs that come out of Alzheimer's medications, for example, drive-up premiums. So those are things that aren't controlled by us and certainly aren't controlled by the Green Mountain Care Board. I don't know if that helps. Just to clarify the record, if there's a Hong Kong-based gather help, we wish them all the luck, but that's not our parent organization and that's not us in any way. So that's that. And we certainly wish to be as transparent as we can be. Certainly with questions like this, we're happy to be transparent, but we are in a competitive space. And so we want to make sure that we sustain. And so whenever you hear us answer a question, we're trying to make sure that the things that we are building, we can build on and actually have, you know, hopefully a successful organization over time. We are not a direct contracting entity. I think your question there, we are part of, again, the Shared Savings Program for Medicare. But Chair Foster, I yield back to you. So that was really helpful. And I hope that addresses your questions, Walter. And if I recall correctly, we had a fairly extensive executive session last year around some of these topics, right? Right. And I thought that was helpful. And I think that our attorney had found the information on that was confidential, which is why we had the executive session as competitively sensitive. Any other public comment at this time? Okay, great. Michelle, can you remind me the schedule of when we next have Laura on our agenda? I think you said it in the beginning, but I've forgotten just for folks on the call here today. Is it December? We have a staff presentation on Monday, November 20th, and a potential vote on Wednesday, December 6th. Next, right. Okay, great. Okay. Well, Dr. Brysicker and Mr. Attala, nice to see you. And thank you for your presentation and your answers and your submission. Thank you. It's good to see all of you again. And we will watch for any follow-ups from the board. So thank you very much. Great. And we certainly owe you, Michelle, a few updates and we'll follow up. Thank you all. We appreciate the time. All right. Have a good day. Bye-bye. Is there any new or old business to come up for the board? Hearing none, is there a motion to adjourn? All in favor, please say aye. Aye. Aye. And thank you very much, Mr. McCracken and Ms. Sawyer. Have a good day, everyone.