 Good afternoon and welcome to the Green Mountain Care Board. My name is Kevin Mullin chair of the board and we're going to get today's meeting started. The first item on the agenda is the executive director's report. Susan Barrett. Thank you Mr. Chair. I have a few announcements. First I want to let folks know that our June board meeting schedule will be posted by the end of this week. We have a very busy month coming up next week so I encourage you all to check that out which it will be on our public meeting section of our website. Secondly as I've said several times before I do want to remind folks that we do have an ongoing public comment taking place. We have a portal on our website for anyone who wants to comment on the potential subsequent agreement with CMMI on an all payer model. We are collecting those comments and sharing those with our partners at AHS and the governor's office as they are taking the lead in the negotiations. And then last I want to update the board on an addition to the agenda. A very small addition although it's important important staff update that will have before the FY21 revised budget discussion from One Care Vermont Marissa Melamed and Elena Barabe will provide about a 10 minute introduction to that presentation. And that is all I have to share today. Thank you. Thank you Susan. The next item on the agenda are the minutes of Wednesday May 19th. Is there a motion. So moved. Second. It's been moved and seconded to approve the minutes of Wednesday May 19th. Is there any discussion. Hearing none. All those in favor of the motion signify by saying aye. Aye. Those opposed signify by saying nay. Thank you. So before we get into the primary focus of today's meeting I know that the health care advocate had wanted to speak to us about an idea he has and so I'll call on Mike Fisher to speak at this time. Thanks Mr. Chair. An idea I have. Maybe a story I have and that leads me to some questions. As you know we get a you know a constant stream of cases of Vermonters who call the health care advocate office with challenges getting access to care and lots of times we're able to really provide help. Lots of times the complexities of interactions between payers and providers and transitions between health systems between between different payers is a really complex world that I am so thankful I have a team that can do the legal research to help people out and we can refer people to the right place. But there are lots of times when we bump into issues where there just really isn't a fix and where any reasonable person would look at it and go why that's just nuts we ought to be able to fix that. And I wanted to tell a story not specific not because I think the specifics of this story is what I want to focus on but because it's sort of indicative of the kind of thing I'm talking about. I have permission to tell to tell more detail but I'm going to stay on this high higher level for the purposes of this. So and I'm not intending to call out any individual hospital or actor here I think these are systemic issues. So patient is working with a specialist I will say at UVM who and the patient and their and their specialist says hey you need to go get this image. Let's look for the right place that's most convenient for you to get the image and they identify a place and the patient does their homework and calls the provider and says hey I'm here's my income I think I'm eligible for patient financial assistance. Is that true and clarifies that they are. They go off and get the image and then the hospital and the image itself is covered but the hospital has a contract with another entity to to read the image Vermont radiologists who for whom the the image is not the reading is not covered by the patient financial assistance. Now that's one problem I don't think anybody hears sort of the contracting of individual of subcontracting for around patient financial assistance that's not that is a problem in this story but it's not the one I'm here to talk about. The dynamic that seems crazy to everyone I've talked to is that you have a specialist who is going to not it's not asking for an image to be read red and you have a hospital who says oh we have to have the image read and it seems to seems to me like reasonable people would say why would we read it twice. Now there might be arguments for quality that having a second reader makes sense but I guess I would question that or maybe I would ask that that well it seems to me like there are examples like this where there's duplicates duplicate efforts that cost the system money in this case costs the individual money that they can't pay that will result in bad debt. And this is not a new story. I've been at this effort for a while. I've been we've been talking about duplication of efforts for ever. I mean ever since I started being here and much longer. And so I ask are there low hanging fruits like this. Are people who live the day to day I'm talking hospital administrators in particular are aware of things that happen regularly that they think boy that should be fixed. That's ridiculous. And that that could be identified evaluated to see whether they there is a fix. I guess I fear a little bit that the likes of me and and you all and people listening people in this meeting are often so focused on broad systemic issues that we miss the low hanging the smaller very important low hanging fruit. So that's I called Kevin earlier and told him the story and he suggested I say it here just to sort of lay it at at your feet and with just a regular recognition of some of the stuff that needs to be fixed. And for some that type of committee to work Mike I really think that you need to have a doctor willing to serve on the committee at a hospital administrator willing to serve on the committee and I'm sure we could come up with a whole list of titles. But the whole purpose of today was to throw that out there to see if there's some interest by some people to start a committee that just looks at all these stories because we all get them and looks at those and maybe tries to share those not so much the details of the story but the lessons that could be learned from the story. And so that's really what we're talking about here today just to see if there's any type of interest to do such a thing. So I don't I don't expect to get anybody to give us instantaneous feedback but maybe we could bring this up again at the next board meeting under old business and just have a little discussion about it and see if there's any any volunteers out there who would like to serve on such a committee. So thank you Mike. Thank you. So with that I'm going to turn the meeting over to Elena and Marissa to introduce us to today's discussion on the 2021 ACO budget. So Marissa. Elena. Hi Chair Mullen. Thank you and good afternoon board members. My remarks this afternoon are going to be pretty brief and I think just me unless Elena has anything to add. I'm really just going to talk to you about the process of the revised 2021 ACO budget. I'm going to show just some slides to orient us. We'll just bear with me a minute. Let me know if they're visible. Yes they are. Great. OK. So the budget guidance and the budget order again. My name is Marissa Melamed. I'm the Health Care Policy Associate Director and Administrator of the ACO oversight process by way of introduction. So the budget guidance and the budget order require a revised ACO budget to be presented in the spring of the budget year. This process is laid out in the budget order and it includes elements described there which I'll show you on a following slide. The budget adjustment process is established in rule five section 5.407 and that is that staff will review and come back to the board with any performance that has varied substantially from its budget. If performance has varied substantially from the ACO's budget then upon application of the ACO the board may adjust the ACO's budget. So what that means is that the ACO may request in an adjustment to their budget as they did last year under the circumstances of the public health emergency and we will review that. Or if a staff identifies a substantial variation then that will also come back before the board and the ACO may request an adjustment to their budget under those circumstances to avoid any sort of enforcement. If a vote is needed it will be noticed. There is no vote for today. If there is no request for an adjustment or no substantial variation is found then no vote is needed. And future analysis will be built off of the revised budget once we are completed with our review. This slide shows the elements that OneCare is required to submit with the revised budget. They include final payer contracts, attribution by payer, the revised budget financial statements using the templates provided by remountant care board staff and any other templates, final descriptions of population health initiatives, hospital dues for 2021 by hospital, hospital risk for 2021 by hospital and payer, documentation of any changes to the overall risk model for 2021, source of funds for its 2021 population health management program, explanation of the value-based incentive fund settlement. The most recent strategic plan and any other information the board deems relevant to ensuring compliance with this order. And the final slide here just has the language on performance review and adjustment under rule 5.407, which I won't read through. And that is all that I have for Marks. If there are any questions about the review or the process we can address those. Otherwise we can turn it over to OneCare for their presentation. Any questions if not we'll turn it over to OneCare team. And whenever you're ready, Vicki. Great, thank you very much. So Vicki Loner, CEO, OneCare Vermont. And I have with me today Tom Boyce, Vice President of Finance, OneCare Vermont. Tom is going to put the slides up for us momentarily in order to just quickly walk through the budget testimony today. I'm going to give a update on our 501C3 application as well as an update, a very quick update on our final strategic plan. Once we get into the execution phase, I am more than happy to come back and talk to the committee about the rollout of the strategic plan. Great. Thanks Tom. I see it. Does everybody else see the screen? We did and of course everybody wants to know who's baby we saw. Oh, that was my mom. Great. All right, Tom, thank you. I wanted to let the board and the members of the public know, although this might be a little bit of stale news at this point in time, that OneCare Vermont did receive approval from the federal government to be recognized as a 501C3 organization. We had submitted our application back in October of last year and in April received the official recognition of the designation that we had indeed been operating and will continue to operate for nonprofit purposes. So this was a milestone moment for OneCare Vermont and certainly validation for us that are operating procedures in the way that we do business really are in furtherance of health care promotion and the primary prevention and programs that we run. So we're very proud of this recognition and we're delighted that this was a fairly expeditious process by the federal government. And that's kudos to the staff and legal team that helped to develop a very thorough process and a special thank you to the secretary of the Agency of Human Services, Mike Smith, who wrote a nice letter to complement the application on the work that we're doing under the LPAIR model. Next slide, Tom. I want to spend the next probably 10 or 15 minutes talking about our strategic planning process and just for our grounding purposes. We did pass the plan that you're about to see in very short form today and this presentation was also provided at our May board of managers meeting in the public session. So it might be a repeat for some of you on today. I would say that this has been a very robust process of the board of managers, the OneCare Vermont team and looking forward over the next three years in terms of what our core capability should be, where should we be focusing our energy and strategies and what would our refreshed mission, vision and values looks like now that we're, you know, close to five years into our operations under this this model and where we want to go to. It was a very intensive process. We structured this in a way to have an outside facilitator who had structured interview questions and processes for over 40 stakeholders. And we have a fairly exhaustive list of those stakeholders that represented our boards, employees at OneCare, our patient and family advisory committee, all the provider association around the state as part of this process that were interviewed as part of our strategic planning process before we even met together as a group to really gather feedback on what were the strengths, weaknesses, opportunities and threats for us as an organization as we as we move into the future. All of this was based and informed off from some presentations and information that we had received from McKinsey and Associates who has a national perspective on ACO's data best practices and what would make them successful. So they kicked off our strategic planning process with presentation to our board of managers and consumers to talk about what a successful ACO would look like and what are some of those core capabilities that we really need to hone in on. As I said, we also really engaged our employees at OneCare. We created a survey for all OneCare employees that really looked at all the same questions that we had had as part of the stakeholder interview questions and rolled that into a survey. We had very good feedback on that survey and really good participation. About 71% of the employees participated in the survey. We were delighted to see that the findings with the stakeholder, the external to OneCare and our internal stakeholders, which are employees, really complimented each other and gave a clear opinion and path for us to move forward. And so that was nice to see that alignment. Also during this process, we had five weeks of a fairly intensive process where we had members, employees, not leaders, but employees within OneCare that represented every department within OneCare that came together with our board members to look at our mission, vision, and values and ask, could we use this as a guidepost to where we want to go in the future? And does it really depict who we are as an organization and where we want to go? And so as part of that process and the approval that went through at our May board meeting was a refreshed mission, vision, and value statement that I think really also does speak to what our core capabilities should be as an ACO moving forward. Next slide, Kyle. This is where we landed with our mission, vision, and values. I'm not going to read it to you because it's big enough font that I think all of you can see it on your screen, but just talk about a few of the concepts in it. In terms of our mission, we really felt like one of the first things that had to be forefront was that this is a partnership between the ACO and its healthcare providers. And really, we are the conduit or the facilitator to help bring many different providers together who are not part of the same organization to work together to drive better care. And the tools that the ACO provides in that is the data and information that they receive from the payers as well as the clinical records and vital, as well as the payment reform programs that we can offer on a more systematic basis to our providers. So that's what you see really came out in the mission statement. Vision is really aspirational of where we want to go and what we want to be. And we felt like it was really important in all the criticisms and discussion about one care is we really do want to be a trusted equitable healthcare system where everybody is rowing in the same direction to achieve that exceptional outcome for care. And that is going to take time to do that. And we recognize that. And so that's what came out as our vision. The values pieces of it was really driven internally by the staff in one care who were very passionate about what was important to them and why this work was meaningful to them. And so as you can see, we landed on collaboration, excellence, innovations, equity, communications and integrity. And there's a lot more detail beyond those words that people really felt like were important in describing what was important to the staff and why people are so passionate about this work. Next slide, Tom. But now I'm going to get into the three main core capabilities as well as the strategies of the ACO. And I just want to say before I go any deeper into the presentation that this again is a very high level overview of ACO core capability strategies and objectives. We have created as part of our strategic plan work plan that would accompany this that will be public facing so that you'll be able to see a lot of the tactics that will go behind all of these these core capabilities and strategies as we move into the future. So the core capability and focus area number one was really going back to that mission of how one care is partnering with disparate provider groups across the state, which does make us very unique in that way that we do have so many organizations that are part of ACO when usually you're looking at one or two clinically integrated systems forming an ACO working together to make sure that the care coordination and clinical practices are streamlined that they were using best practices and as much as possible to really standardize those and the way that the ACO can support that is through a lot of the targeted supports and data that we have around care coordination, the training, the best practices, the assistance in helping people through certification for becoming a certified care manager and establishing those clear expectations on what success looks like in certain common critical areas and what we try to do as part of this process is to really tie it to the all-payer model improvement plan and some of the high level as well as tactical goals that the improvement plan is trying to set and in terms of how this fits in, it's really about that strengthening of integration and improving collaboration among the various health care providers so that you don't have duplication or redundancies for patients in the health care process. Next slide. The second one is talking about really elevating those data and analytics capabilities in order to optimize patient care delivery. When one care first started off, we did a lot of asking providers to kind of self-service, look at information, we provided elbow support with that and now what we're looking to do is to talk with the health care providers or what are some of the key data points that they really need to focus on that might be a variance in their select hospital or health service area and optimizing that data to help them around their performance goals that are set and agreed upon at the ACO level. So that's really providing that insightful information to help guide better patient care. And we believe that really, if you think about the all-pair model improvement goals, this is really about delivering actionable data so that if a patient ends up in the emergency room or an inpatient admission, that they can get an immediate trigger to the health care provider to let them know that services are needed even if they're not within the four walls of their building. Next slide. And the last one is a big one. It's really around providing a vehicle in a way that brings along the federal government payment system that's more predictable and is tied to value. And there's many different ways in which you can tie payment to value. Fixed payments is, of course, one of them. You can also have your savings programs. You can have payments that are tied to certain quality outcomes. So it really is a spectrum. And so what we're looking to do as an organization is really make sure that all of our payments and all of the services within OneCare have a value component tied to them so that providers can have that predictable payment stream that they can rely on to best serve their patients. And a few of the objectives really for us is looking at some of the value-based payment contracts that have a fixed payment. Medicare being one of those that really we need to drive and work with the federal government to have a payment that's not reconciled at the end of the year because that's not supportive of health care reform efforts. And really looking at our current independent primary care program that we have, which is for all payers, Medicaid, Medicare and commercial, and seeing how we can simplify that, align that with federal programs, and move it above and beyond independent primary care to be an avenue for even FQHCs and hospital-owned practices to participate. So you have one payment model for all of primary care. And tying that back to the high level, I'll pair model improvement goals of really increasing the percentage of Medicare and commercial payments tied to it. And that concludes the high-level overview of our strategic focus areas, core capabilities, and refreshed mission vision and values. As I said, we have a larger packet that has a lot more details in it that we'll be putting on our website within the next seven days or so, getting that cleaned up. And all along the way, we've been talking to all the stakeholders who have provided input to really bring them with us and give input along the way of this process so that when we got to the end result, it had, it was continuously improved along the way because of people's input and advice on the strategic plan. So we're quite happy with the level of engagement that went into this process. We're happy that it really ties to a lot of the national perspective of what makes ACO successful. And we're looking forward to the next kind of leg of the journey where we'll be looking at that work plan and executing accordingly. Now I think I'll turn it over to Tom Boris to talk about the revised budget. Thank you, Vicki. So Vicki back on Morris's intro, we've developed a pretty routine cycle over the last few years where we present our budget to the Green Mountain Care Board in the fall and winter. And that budget inherently has many estimates. We're estimating total cost of care, benchmarks, we're estimating attribution, and in some cases we're anticipating what lands in contract but may or may not actually be included once the negotiations are final. So because of the number of variables in that initial budget submission, I think it's a nice practice to come back here and present with a little bit more certainty of certain numbers that affect our entire budget model. So that's what we're going to hear about today. I'm going to do my best to give a pretty general overview of all the different components of the one care budget at a higher level and I'm happy to go deeper. I also just for those on the call here today, for those who want to go deeper, the submitted Excel templates have much more detail than what's presented here in these slides. In some cases just can't even fit it on a slide in a way that's readable. So I invite you all to look at those materials as well. So getting started on attribution, I'm going to point out a couple of things that I find interesting here. I'm going to start by explaining two different perspectives on attribution. If you look on the table under the green section is what I've labeled starting attribution and under the blue section I've labeled average attribution. We often for the purposes of scale speak of starting attribution. That's the initial list we receive from payers and in some cases that's even before the performance year begins, particularly for the public payers. Our budget though is largely built on average attribution, which to some could be translated to member months or the July 1st period. We use that average attribution so as to not overstate financial terms. For example, we're paying a 325 PMPM. If we use that starting number, it means our budget will overestimate or over project how much we'd actually spend. So when we build our budget, just about all the figures are going to be referencing back to that average attribution. So with that, I'll just highlight a few notes that I find interesting this year. First, Medicare attribution started high, almost 62,000, a little bit above what we anticipated. But we lost over 7,000 lives before the performance year even began. And we usually lose some. This was a higher number. And the reasons are some of these lives pass away before the year began. Some moved to an MA plan or are exempted from the program for other technical reasons through Medicare. So when it translates to the budget, when we think about the starting attribution actually above target, but after factoring in the loss that we anticipated before the year began, we're actually down about 8,800 lives on an average attribution basis. So you'll see the way that this threads through the budget later on. Medicaid expanded was an interesting one. Attribution came in really strong, about 6,200 above the initial budget. What we learned in 2020, and this was the first, that was the first year of this cohort, was that the attrition rate for this group was much higher than we expected. We anticipated when we built the original budget for 2020 that the attrition rate would be somewhat similar to Medicaid traditional. So those that with the primary care relationship, but we observed through the year that the attrition rate was much higher. I'm curious honestly to see if this continues into 2021, if it was in some way or another affected by the pandemic, but that is a change. So numbers came in high, but when it comes to an actual budget figure, it basically washes out and is pretty close to what we anticipated. Another big number here is the Blue Cross primary non-risk. These are health plans that have chosen not to put their employees or cover lives into a value-based program with Blue Cross and with One Care as well. Pretty significant reduction. This has to do with just fewer health plans using Blue Cross primary. Blue Cross has their TPA, not something we could have predicted when this initial budget was built. So we don't even get a lot of data on these lives. We don't get any specific data. We only get aggregate, so I can't speak to it anymore than that. Next is the movement to program total costs of care targets. Noting that attribution was down in a couple of areas, pretty similar themes. Public health emergency must be stated that it's just creating some new and evolving cost patterns. When we built the original budget, we had very little sense of what was going to occur into 2021. And I remember having calls with actuaries. There's a lot doing public sessions to explain the results. And you could listen to two back-to-back, and one would say 2021 was going to have low costs, and the other would say that 2021 would have high costs due to pent-up demand or kind of catch up. We budgeted in the initial round based on status quo models really not knowing what was going to occur into 2021. As it turns out, many of the targets came in a little bit lower than we anticipated, so you see that it is down. In Medicare, a large portion of that reduction is due to those 8,000 lives with each Medicare beneficiary having such a high spend per life. It consumes more than half of that reduction. And as you go on through, it's really where the targets as set by the payers landed that dictated the lower total cost of care. This specifically doesn't have an impact on one care operations. It's really just the total cost of care accountability figures, so no concerns from an operational standpoint of one care as a business entity. I've also supplied a slide with the provider payment breakdown, with fever service, and then the other three four components being the fixed payment. 34% has been converted to a fixed payment model. That's unchanged in the original budget submission. Apologies for the redactions. A little bit of the nature of this business here. But again, flowing through a programmatic risk overall and reward is down in alignment with total cost of care changes. So generally risk and reward is linked to that total cost of care on a percentage basis. So as those total cost of care target numbers go down, so too does aggregate risk. Public payer programs, Medicaid, Medicare have adjustments related to the pandemic that are important to note. COVID-19 episodes are removed. So if somebody is hospitalized for COVID-19, that hospitalization as well as the following month of care is deleted from the actual spend. And the max downside risk is prorated down for each month. The public health emergency is in effect. This at present has been extended through July. So effectively seven months of the year will be prorated down. When we look at the numbers in aggregate, the downside estimate based on these revised figures here is just shy of 16 million, 15.6 in fact. And on the upside, it is 16.8. The difference between those two, the upside being higher is that one program's an upside only, so there's no downside, but there is some upside potential. The bottom table, I've taken the opportunity to just calculate out the current prorations based on the duration of the public health emergency through today's knowledge. So basically the Medicare and Medicaid programs, the maximum risk that will be owed by one care is now down, prorated down through July. So in total, really the maximum downside risk about six and a half million, if that public health emergency is extended again, they typically go with 90 day blocks, we'd see that amount reduced accordingly. That does not change the upside. So we retain the opportunity for shared savings without any effect of this proration figure. Risk sharing model, just a quick update. Really no substantial changes. Last year's big evolution was trying to expand accountability and opportunity more broadly across the network. Historically, it was fully the responsibility of the hospitals on both the downside and the upside, and as a means to help improve the focus on performance to more of the participants in the network, we have now implemented a $1.50 PMPM contribution, which can either be processed monthly or deferred with a potential for invoice at the end of the year to all attributing primary care. This includes FQHCs, independence, and hospital employees as well. And then we also offer these participants a $1.50 PMPM of shared savings if earned. So they have the first swath of any shared savings earned goes right to primary care, and then the hospitals pick up the balance from that point on. In the table, I've broken down the different components. You can see the primary care share on the downside, about $2.4 million. The risk-bearing entity being the hospitals, $13.1 million, and there's that total risk of about $15.6 million. Similar pattern on the upside. Risk, total risk breakdown by HSA. I've summarized it a little bit here just to fit on the slide. There is a breakdown by payer and HSA in the submitted budget templates. But you all to look there. I've also taken a liberty on this tab to break down non-hospital PCP share of any downside risk versus hospital PCP, and then lastly the risk-bearing entity. Because some hospitals employ primary care, they have risk and reward opportunity, both for their primary care component and for their hospital component as their risk-bearing entity. So you can see about $1.3 million of the downside risk and reward effectively goes to non-hospital PCP, $1.1 million to hospital PCP, and then $13 million to the risk-bearing entity really is the hospital. In terms of scope, 85% still lives with the hospitals, the risk-bearing entity. So the majority of risk still lives there. But I think adding the financial accountability to all primary care is an important step. This is a big evolution in 2021's budget, was quality accountability, just to bring everyone up to present. One of the strategies that we employed to really help manage hospital participation fees was to shift quality accountability to settlement. Some of this was COVID related, everyone was all the participants were under some financial stress, but this is also a strategy for long-term sustainability. Historically in the model that we operated with the payers, we had to pre-fund quality accountability into the value-based incentive fund, and the means to do that is to add it to hospital dues. As our programs grew so aggressively over the last few years, the amount that was being added onto the hospital participation fees to pre-fund this value-based incentive fund became substantial and it was resulting in aggressive dues growth over time. So what we endeavored to do in the 2021 budget and the negotiations with payers was move some quality accountability to settlement, and this is actually a little bit of a more traditional model where basically you can earn shared savings or O-losses, but your quality score affects how much you can get or owe. So if you earn shared savings but had a really poor quality score, you wouldn't actually be entitled to those shared savings. For example, a little bit more of a traditional model. You see that in the MSCP program, in fact, and that's the way the Medicare program that One Care has participated in the last for the last few years technically works. Where this landed is Medicaid made it up, splitting it in half, half is pre-funded, half moves to settlement. You see that on the slide there, but we were successful in the commercial program negotiations to move it all to settlement in the back end. What it means about 2.2 million is pre-funded. That's a more palatable number. 6.3 is what I call at risk at settlement, meaning that if we got a zero quality score across all programs, 6.3 million dollars is technically at risk, and then total quality accountability when you add them both up about 8.5 million. Just for reference in 2020, quality accountability was 5.6 million, the problem being it all needed to be pre-funded. All right, shifting a little bit more into the budget for the One Care entity itself, talking about revenues here. No major changes in the overall payer contribution model. Many have some sort of a PMPM contribution that will flow through to the participants in the network. No significant changes. The numbers just will move with attribution. In the state funding for DSR and health information technology, there's a little bit of a juggle, no net change. But in the original budget, we anticipated 3.9 million dollars of DSR funding and zero dollars of health information technology funding. At the time, it was believed that those HIT funds were unavailable for 2021. Fast forward to today, some HIT funding is available. We've now budgeted a million dollars of that, but it's offset by the DSR. So DSR is down to 2.9. So think of those two as just a trade of source funds from the state side, but in total the same 3.9 million. We have yet to formally contract with the state for the DSR funds, but all signals are green as far as I'm aware regarding the DSR funding, making it through the legislative process. I'll just note the blueprint self-management was an initiative that we had planned back when the original budget was being designed. This ultimately did not launch, so that's why this has been deleted. Lastly, on this slide, deferred revenue. We anticipated using a little bit more of these funds in 2020, but the pandemic just caused everyone to focus on protecting their patients, protecting their employees. So a lot of the projects we had planned for 2020 just got delayed and deferred. So it's really a timing shift where more of these will occur in 2021 rather than 2020. Population help management investments break down. I'll just note it was nearly impossible to fit it on one slide. There is a sources and uses table in the budget templates that show for each of these different investment areas as well as our operations, which revenue streams or funding streams support the different projects. But in total, main changes came from attribution sheriffs. So you see the base 1K Vermont PMPM down about 1.2 fully based on attribution. The self-management program payments that program did not launch. Therefore, the expenses that would have gone to the network deleted accordingly. And then as I mentioned before, in the specialist innovation, some timing related to the public health emergency just delaying or deferring some projects out into 2021. Operating costs, we did go through the budget in detail. I'll say there were not substantial shifts. When we did our second budget in 2020, many of the changes were designed to be flowed through pretty seamlessly to 2021. Some of the same question marks about what our return to the office configuration looks like remains as we continue to evaluate that just like many other businesses. Wages and fringes made a few updates for hiring dates. Some positions we anticipated to have on board by now and they haven't been. So just adjusted that accordingly. In the contract in space, legal spent a hot expense of late. So we've adjusted that accordingly as well. In the occupancy, we're able to reduce the rent expense for the business. So we've updated that figure also. I'll note that we had really three different versions of our operating costs here. We submitted an original budget of 16.1. During that process, became aware that the amount we budgeted for the Green Mountain Care Board billback was too high. So we updated that and made the approved budget column reflective of the reduced billback number. So that's where you get from 16.1 to 15.9. The budget while we've juggled categories a little bit remains unchanged. Participation fee breakdown, a lot of numbers on this tab and our slide, I'm sorry, shows a very similar story, but there's an important point I do want to make. Starting the left original budget we submitted, approved budget reflects that Green Mountain Care Board billback update accordingly. The revised budget has $15,056,000 for participation fees. So relating back to the original budget, up $120,000, which when you spread it out, isn't terribly substantial across participants versus the revised up a little bit more. The participation fee amount is really the most variable component of our budget. And depending on attribution across programs, other revenues were able to secure from third parties, the state, et cetera. That can affect the dues amount of coordinates. So think of it in this way, if we were to get a lot more funding from a third party source, the offset is a reduction in hospital dues. So there are many moving parts in there, but in general, it ended up being pretty close. I was reasonably happy with the result, but all the changes ups and downs are really due to attribution shifts between what funding streams come into OneCare and then what is therefore left for the hospitals to pick up the tab on. Some are up and some are down. As over the years, we've developed a methodology for allocating those participation fees across hospitals that contemplates which hospitals have employee primary care and which don't. Otherwise, the net cost would be very substantial to a hospital that doesn't have employee primary care, where one that has primary care gets a lot of funds back through OneCare programs. So on a net basis, we have much lower costs. So over the years, we've worked closely with our network to develop a model. And any shifts in attribution between the HSAs or between the hospitals will result in some ups and downs on a per-hospital basis. Again, this is a highly summarized view. There's a much more robust income statement, profit and loss statement, including the Excel templates. We've done some work. It's been a nice collaborative process with the Greenland Care Board staff to evolve the templates and make it a little bit more clear. I'll speak to it at a higher level in terms of the revenues. A lot of what we call revenue in our budget is completely external to OneCare in the sense that, yes, we're accountable, but we never actually touch the dollars. So that has been converted into its own category, external total cost of care. Note that is down. That's just the total cost of care targets going down. Contract revenue relates to all the contracts with the payers, mostly a couple small ones here and there in addition. But that will also include the fixed payment component. We do touch those dollars. So we've included that in a bucket that actually does flow through OneCare Vermont. That $68 million reduction is linked directly to the total cost of care and the lower fixed payment amounts accordingly. Other changes are relatively small, just other revenue and hospital participation fees that we spoke of. Very similar breakdown on the expense side. The external healthcare costs, we don't touch those. The PHM program expenses, we call the fixed payment part of that internally often. This really is a tool for us to invest in population health management and see that row accordingly. And then operating expenses, again, unchanged from what I'm thinking of as the approved budget version. In all circumstances, net income is set to be zero. Balance sheet relatively unchanged, really. This is a balance sheet forecast or projection of what December 31st, 2021 will look like. Largely, those assumptions have not changed. We're such a heavy pass-through organization that just about everything on the balance sheet is a timing-related component. What do we think our fixed payment for Medicaid will be? They pay us actually a month in advance, typically. How much will be there on December 31st is kind of the guess. What do we think is going to be outstanding for any payables or receivables? So really not any significant changes in the line-ups. One area that is noteworthy is in the equity section. With our 501c3 change, no longer are the retained earnings booked in the same fashion, typically the way that that worked through the partnership accounting model. Was that any equity was really split half-and-half, Dartmouth and UVM to organize the business in a manner that is compliant and consistent with the 501c3 status. We're changing this row to be net assets. Those assets really belong to one care in total and don't flow through to the founders in the same way they historically have. So much more consistent with what you would see on a nonprofit balance sheet. And that's the high level. Happy to entertain questions. Thank you, Tom. Do we have questions from the board? This is Robin. I have a couple questions. Go ahead, Robin. Okay. Hi, Tom and Vicki. Thanks for joining us today. So I had a question around the Medicare attribution. Do you have any sense of how much Medicare Advantage is driving that versus the other issues you rattled off? It is a component. We can supply a breakdown to you, and I haven't prepared that today, but yes, we've noticed an increase in Medicare Advantage in this over the last two years, really. It seems to be a much more present option for remonters in terms of their healthcare coverage plan. That'd be great. It'd just be nice to understand a little bit. Certainly some of that could have been the pandemic, I guess, or who knows what. But it just would be nice to kind of understand why that was such a big drop this year. Sure thing. I was wondering if there were any substantial or substantive changes to the commercial programs in terms of the programmatic aspects since we last saw you in the fall? I'd say the high-level answers no. Really, I think the idea that we implemented was to, in 2020, when we're all kind of going day by day through the pandemic, find a way to make the program as kind of low risk as possible for participants. We largely kept that in similar form and function, rolling into 2021 as uncertainties so revolves around us. As we move forward, I think we want to start working and back towards a more traditional looking and feeling model, just as we as a society start to get back to a little bit more of a normal existence. Great. And I did notice in the budget template document that you submitted and the full accountability tag, their MVP had two different breakouts. One was PHM and one was an other. And then SIGNA had some consulting revenues. And I wonder if you could just explain that a little bit. I didn't remember that distinction from the fall. So it may be my faulty memory. No, no, it's okay. I don't think I'm going to be saying anything that gets us out of our sideways with the commercial pairs. But we initially worked with MVP to develop a model where they contributed to the care coordination program. And it was kind of an in and out. They would contribute during the year, but it became a healthcare expense or cost at settlement. So kind of came out in the wash at the end of the day. For administrative efficiency, we agreed to just go do away with that portion of it. It wasn't a tremendous amount of money based on the size of the population. Okay. And then what's the SIGNA? SIGNA is it's not we not directly with SIGNA, but we have had a staff person on board that helps with the some participants in our network that are in a SIGNA collaborative accountable care program. It was kind of similar thing where they paid us, we have supplied the employee, we decided to transition that work entirely back to the participants engaged in that program rather than having it kind of flow back and forth between us. Got it. Thank you. And then also programmatically, I was wondering if there's any sense yet about restarting some of the programs that were put on hold, understandably with COVID. And I know we're all just starting to come out, so you may not know that yet. But if you had any sense of timing and when you might restart programs, if you think that's likely in 2021. I can speak for us at one care. We're looking to get back into all the same things we were interested in doing prior to the pandemic. We can supply some sort of a little template or update on the specific initiatives and their timing if that would be helpful to you. You may be doing that already in the reporting manual. So certainly if it's duplicative, I was just curious about that because certainly that would be good news. And then my last question was on the strategic plan. And my question actually stems from the longer PowerPoint document, which has more of a timeframe for certain objectives. And I was wondering if you could speak a little bit more, Vicki, to your timing around commercial versus Medicare in terms of moving towards fixed payments. And also you may know we had a presentation a couple of weeks ago around FQHC participation. And if you had any sense about FQHC payment models, that might be in the offing. That might be a preview for 2022. But I was just curious about that given that we just heard about that. Yeah, that's great. Thanks, Robin. Yeah, our first push is really towards the Medicare program. That's where the preponderance of our lies and dollars flow. And so moving the federal government in that direction and getting a program with them, it's much easier to get the rest of the state to follow in that direction. So that's where we'd like to focus our efforts is getting the Medicare to a truly fixed payment approach. They do offer that with other programs. And so I think it's going to be a discussion about how much risk and reward that we're able to take as a network. And so that's also going to take some time to make sure that the delivery system is really assembled to make those necessary adjustments to both risk and reward. Ultimately, we need to get to higher risk corridors than we're at right now to be able to continue to fund all these investments that we're making because currently as it stands, the amount of investments are far exceeding the amount of shared savings opportunity. And that's just not kind of a sustainable option for us. As we move through the CPR for the independence this year and a simplification process, our goal is to broaden that out to FQHCs as well as hospital-owned practices. So as part of this process this year, we want to look at what are some of those steps that we could take to be able to have that offering come 2020, what year are we in now? 2023 so that we would have our standard program in 2022 that would be simplified and a little different. And then we would have a broader offering in 2023. I think we're often caught up in this contracting cycle in that we have to have our contracts out to providers by June to be able to have them signed by September. So that means a lot of things have to be known by June and we're just not in that space for the FQHCs or the primary care hospital-owned at this point in time. So it's a little bit of that. So Tom and Derek Reigns, who's our new director of payment reform is going to be working to assemble the CPR practices and designing that later on, well, next month. I think I've got all your questions. Did I miss anything, Robin? I don't think so. No, I don't think so. The only thing I would note, which is obviously my opinion, I'm one of five, but I think the board is going to be very interested in seeing the commercial programs evolve simultaneously with Medicare, at least I am, because I think that otherwise you get into some strange dynamics in terms of payment policy and potentially putting too much pressure on commercial premium payers. So just a heads up that I think, at least for me, you'll be getting a little pushback on that timing because I think we need to be moving forward on both fronts. But again, that's just one of five. Thank you, Tom. I do think that's a good discussion to have and probably one to have with the payers too because they need to be able to operationalize it. Right now they offer a reconciled AIPVP and we're not interested in continuing that approach. So really it would mean getting to a state that's truly fixed that we could take on. Great, thank you. You're welcome. I just have one question on the risk reserve chart where I guess it's prorated down for the downside risk, but the upside opportunity remains in full. Is that the case? I mean, because it appears there should be a bit of upside potentially. Yeah, that follows the national Medicare model that they implemented in 2020 where they limited upside to 5% and it's funny to say it that way because 5% feels like a lot, but some ACOs were at a 15% risk quarter. It's an option. So they limited it down to 5% to prevent, I guess from windfall shared savings to ACOs across the country and alongside that added the proration of downside risk for the months of the public health emergency. So I think through their lens, they did both upside and downside for us. It ends up being more of a downside benefit and upside remains unchanged. Okay, good. Yeah, thank you and thank you both for the presentation. Sure thing. Thank you. Other board questions? Yeah, I have a couple. I want to thank Tom and Vicki for this presentation and all the work that went into the strategic plan. My kind of long-term sense of things is that a lot of people, I think, or some people don't appreciate the work that had just taken over the early years of the ACO just to establish itself and create the infrastructure that is now not mature, certainly, but is seasoned. And there are some areas where success of the ACO is clear on the ground. There was an article in Vermont Digger a while back about the Southern Vermont Hospital and their transition in terms of outpatient versus inpatient caseload. And the folks down there give the ACO a lot of credit because it helped them kind of weather the transition from fee-for-service to a fixed payment model and has really changed care down in that area. But as we kind of go forward for me, maybe being too simple, but I'm looking at the strategic report where it says increase on slide eight, you don't have to go there, but it says increase the proportion of value-based contracts that have true fixed payments in 2022 and beyond. And my mind immediately goes to, well, what is the proportion now? What is the tipping point, which is a question we asked in the last budget process? And what is the goal for 2023? So that when we're talking to folks about fixed prospective payments, especially true ones, we know what the plan is. And for me as a board member, knowing what the plan and understanding that you're just a portion of the pie, but understanding where you are and where you want to go is information that I would think would be helpful in rate review in the hospital budgets. So, and the same for the language in the plan that talks about increasing proportion of independent primary care practices in true capitated programs. But there's nothing that I've seen yet that let me know where we are. And I understand that it's taken a few years to get to where we are, but where we are now and where we want to go. So that's just kind of a comic going forward, looking at the next budget process. Another issue that I think maybe is some significance is in the appropriations bill that just passed, there was a section that called for the review of the benchmark plan. And it looks like you have about 22,000 folks of attributed lives. That are subject to the benchmark plan. And so there's going to be a review of that the first time it's been done, I think since 2013 or 2014. And I would think given your analytic capabilities or in history now that you might be able to help inform that process as to how our benchmark plan might be changed to better emphasize population health and our preventive care approaches. It's a one-time opportunity. I think they have to have a report out by January 1st of 2022. And I would think the ACO would want to be engaged in that given your capabilities to profile the healthcare system. So that's just, I guess my question is, were you aware of that section in the appropriations bill? Personally, no. Well, it's a section E227. And you'll see it's significant relative to the folks that you have in your attributed lives that are in the QHP program. Another question I have is a couple of weeks back we had Michael Baylett from the Baylett company, which has a long history and kind of engagement at different levels in Vermont. And one of the points that he made in terms of the strategic, his strategic report referencing qualities of a successful ACO, he said that one, his top point was that they are characterized by, quote, moving care from high cost to low cost sites, e.g. away from hospitals. That was his top observation about successful ACOs. And I'm just wondering what your reaction to that observation might be. Yeah, it sounds surprising one to me. It goes along with that right care, right place, right time, and cliche that it's thrown around pretty often. I think I've seen, at least heard from a number of different ACOs. They all have a different strategy that they play. But generally speaking, there are, maybe I'll call it two camps. One is in that vein, which is really care, almost referral management. How do you make sure that the patients land in the right place, go to home health when it's appropriate to do so, rather than staying in an inpatient setting and really coordinating that from a referral standpoint. Others go after savings through population health and really trying to help improve the population wellness and really using primary care as the quarterback to do that. We're more in the latter. I think we really use primary care to be the one responsible for taking care of their patients in a holistic way and ensuring that they're getting the care in the right place rather than having one care with a team of people that kind of point and say, go here, go there. But ultimately, if we're wildly successful in this venture, it is the hospital revenues that would suffer, I'll say, at least for them. So the couple strategies to help keep them really engaged in it and participate in the programs, fix payments, get into that true unrecognized fixed payment where if you can avoid an admission, there's every financial incentive to do so and over time start to redeploy resources to upstream services rather than inpatient and then giving the hospitals a reasonable stake at the shared savings as well. And I said at the beginning it was really important to broaden accountability. The end there is also giving the hospitals some opportunity for shared savings too because they're the ones that would see less revenue than their ED inpatient, which is good, but it keeps them incentivized. And I've spoken to other ACOs that are just primary care which is kind of your more typical ACO and to them the hospitals are the enemy. It's a very adversarial relationship where the hospitals will look at the ACO activities as you're a threat to our revenues and having a more diverse network that includes hospitals and primary care and home health, et cetera, I think enables us to really take on that second strategy of really working on the health of the population and putting the providers in control. I would just add on to what Tom said at the end about us being a very unique accountable care organization and that we do have providers that across the spectrum of care. And if you even look at one of the Medicare benefit enhancements is that three-day waiver. So that's avoiding people going to the hospital prior to entering a skilled nursing facility. Vermont is third in the country in leveraging that waiver. So I would say that our healthcare providers have really embraced this work of really working together as a system for the betterment of the patient. Now it can't be at the expense of a hospital going out of business because that certainly doesn't benefit the community if they have no place to receive their services in the future. So I think it's recognizing that one care and its provider networks are really ahead in that area. Well, thank you for that. My closing observation is that as we go forward that the strategic plan was well written. I mean, it was interesting to read easily understandable but there wasn't a lot of meat there in terms of information like what's the proportion of FPP that we have now that one could grab onto. And so as we go forward, given that the ACO is a more seasoned organization now than it was say two or three years ago, that we begin to populate that strategic plan with metrics and data that allow people to understand the story and the benefits of the ACO and that they don't get lost in this overall complexity of our healthcare system. So thank you very much for that. Thank you, Tom. Other members of the board? Sure. I'll jump in here. And actually, it's great to go last because some of my questions were already asked. But just to jump on Tom to the answer to Tom's question about sort of the low value care and the comments from the consultant that we heard from a couple of weeks ago about high performing ACOs thinking about referrals to lower cost centers. And I guess I would just say that in your strategic plan there's a discussion about courage to challenge existing systems and there's comments about best practices and clinical practices. And we just heard from Mike Fisher about some stories out there about some duplicative services and low value care that's adding cost to the system without adding any quality to the system. And so I would just hope that your approach would be too pronged and also thinking about how to eliminate some low value care from the system. So I would just add that to my hope that there is room for that in your strategic plan. My question, I have two questions, I think, that are still lurking. One is you've changed your financial accountability with your risk sharing model this year and you also changed the quality accountability with the settlement now dependent on quality score. So I was wondering, I know you're just in it right now but I'm wondering how that was received by your networks if you can just speak a little bit to the changes that you made in this budget cycle and how it's being received. Generally, I think it's being received okay. So to start at the risk sharing model, we are now kind of in a more kind of pro rata way distributing shared savings to HSAs. That I think has been well received in the context of it makes sense during the pandemic but I think there's also a shared recognition that what's lost and that is some more localized accountability. And the way I think of one care along its journey is we came out with a pretty complex model in the beginning honestly and this in a way is an opportunity. I mean the pandemic was the catalyst for it which I never wish for but we now have a pretty simple model and it's almost in a way a clean slate to start building accountability back out in a more thoughtful way. So the $1.50 PMPM is part of that and the value based incentive fund is part of that starting to get back into a model that I think is easier to understand for our participants really effective. I want the whatever financial models we developed to be effective in driving the right activities and behaviors and in a way I think this is an opportunity to kind of reset and get going again in a little bit more of a methodical way. And then along the way there's always an interesting dynamic some I'm not sure anybody loves the $1.50 accountability being spread but a lot understand it. I mean the first word in ACO is accountable and I think there's kind of a shared understanding that needs to be there and it's an important part of this evolution even though it's tough and the timing is tough too. I mean doing it during a pandemic was just bad luck honestly but important nonetheless. Okay thank you and my second question was about the DSR funding. I understand you know the 3.9 was what you expected 2.9 is what you got it doesn't to some degree matter for this budget cycle because you also had an unexpected 1 million from HIT so at the end of the day you had the same amount but I'm wondering if there are any insights you gleaned in terms of your below expectations on the DSR what does that mean for 2022 and is there any remaining money left in HIT for next year? I'm just sort of wondering what you learned from this cycle that might actually inform next year's budget even though I know we're not talking about next year's budget but you know funding sources in the future learnings. You're new to Vicki. That's a great question. I would say that we what we've learned from this is that there needs to be a predictable funding source for investments moving forward that going from year to year doesn't create the type of predictability that's needed for the healthcare providers to know that programs are going to exist into the future and so I think we have a couple of choices in front of us either we have to learn how to live from the shared savings opportunity and cap our investments at that or there has to be a conscious decision on behalf of the state to invest some money up front to help primary care behavioral health mental health providers and others really get prepared to enter into value-based contracts. So I think we have two choices. We can either choose to make some predictable investments up front or the ACO needs to look at what its potential is for savings opportunity and base its investments off from that. Did part of your strategic plan do any kind of analysis on what types and value of you know or the level of investment that would be needed to really make delivery system reform change what the ask might have to be going forward? Is there any is that a part of your strategic planning exercise? We had started that I would say that's more in the execution piece of it but we did have discussions that we could put out there what we really would need to be able to make this work. I think when the all-payer model originally was looked at there was a lot of money available to invest that money did not come to fruition as anticipated and so we have to think about that moving forward. Great thank you those are my questions Kevin. Thank you Jess. Does any board member have any follow-up questions? I just have one based on sort of your dialogue with Jess. One of the and I'll just make it as a comment you know you can think about it and in terms of your strategic planning but you know as I've talked about many times before there's kind of different pieces to payment and delivery system reform one of which is provider readiness and the ability to ensure that providers have the technical expertise to do the actual on-the-ground delivery system reform change which is going to solve the problem like what Mike Fisher brought up today. So I'm just curious when you're thinking about what level of investment to think about that in terms of not just investment to the ACO but investment in technical assistance because it looks like that's the piece that I'm still feeling could be missing. I don't understand whose job it is to ensure that the technical assistance is there in our not not with the ACO but in the in the whole system whether it's the state that it could be the state it could be the ACO it could be the provider level I think any could work but that still feels like a gap potentially to me. I would say Robin we really tried to get at that in a longer document that I think you have a copy of that looks at what are the ACO core capabilities versus what's the network core capabilities because those are the direct care providers that are on the ground trying to deliver the service. So when I talk about investments I don't mean investments in the ACO I mean investments in the providers like the primary care incentive fund that we give for the CPR like how do those investments get made in a way that's strong enough and sustainable enough to help them move to a truly capitated system that they know is actually that's the direction they're moving versus like well it might be this way for a year but then we might change our mind right and we'll go into different direction. So to make it a sustainable long-term investment for them. So it's really on the provider side that I'm talking about making the investment and not on the ACO side. Thanks. Okay at this time we're going to open it up for public comment. Members of the public have comment please raise your hand or if you're not on the teams meeting just speak up but I will call those with their hands raised first and I'm going to start with I'm going to start with Ham Davis and followed by Mike Fischer and Walter Carpenter so Ham. Ham? Yeah can you hear me now I'm sorry that was my fault. Yeah we can hear you now Ham. You're so lucky. I'd like to go back to Tom Pelham's question one of his questions one I think that didn't get answered on it but I think is absolutely critical and I think it's one that the chairman has talked about on two or three occasions over the last several months and that is I think we need to know where we are right now in so far as the actual number of fixed price contracts prospective real prospective contracts and how much ground that is covering because I think because the whole thesis of healthcare reform is to shift from people service to capitation and I so I really want to know what Tom's question is we've had different numbers I mean the numbers we I've seen numbers as low as 2% and as high as 20% somebody said 2% AHS said no 2% wasn't right but they didn't say what was right so I'd like to know how much what have we got right now that we've actually accomplished that's got that's got the renewed got the new reform payment structure in place I think a second one if I be so just together all at once is I think Tom's question also included that's Tom Pelham's question also included where he thinks the tipping point is we know we're near the tipping point but the tipping point is very interesting it's probably my judgment somewhere around 40 but on paper anyway it's supposed to be around 70 so could we get the questions to I'd like to get those that answer to and I'd like to get answers to those particular questions that Tom asked thank you I would just like to offer Mullen that we do have a breakdown there is a national consultant group that looks at by value-based payment type because again it's a it's a continuum so having fixed perspective payment might be a gold standard but it's not the only value-based payment so we have 1.4 billion dollars in value-based payments that's one carers number that's probably close to I looked at Tom half of what would be eligible to be in value-based payment care but we do have it by value-based payment type at least for one carers book of business yeah I mean I'm going to respond that too I mean the the question hit on a couple different components I'll try to break them apart a little bit moving away from fee for service isn't uh synonymous with value-based healthcare payments and Medicare through you know MACRA and all the evolutions it's made over the last few years has basically said we're now paying providers for high value care high quality care but it's still reimbursed on a fee for service basis so with that in mind Vicki's 100% right we have over a billion dollars of healthcare in a value-based concept whereby providers are rewarded for high quality care that lives within a total cost of care target and with our very progressive model we'll pay back if if that target is exceeded in terms of and I'm referencing a Greenland Care Board presentation about how much of the total healthcare costs for Vermonters is even underneath the all-payer model umbrella somewhere in the two and a half billion dollar range so we're near 50% of all Vermont Vermonters healthcare costs being in a value-based healthcare arrangement I don't have national data but I'll just speculate at the risk of doing so that it that's a pretty high penetration rate relative to other states in the in the country it's it's growing nationally but that's that's a pretty high penetration rate to me the second question I think gets at the fixed payment and is more of on a provider level so if I'm a hospital or a primary care or home health shop what's what's the tipping point there for a fixed payment that that changes the way I you know do business and that's that's a tough one for one care to answer honestly because we don't know how much of their business is outside of the one care programs but it'd be a great question to ask providers what's what's that tipping point where you really can start doing business differently in my past experience payment reforms were often more like program by programs and just getting one program switched over was a huge win even if it was only one percent of your total work I'm not sure if that same paradigm holds true for a hospital or a primary care shop can I follow up on that Kevin or I might go ahead yeah I understand that there's a lot of different ways of looking at the when when CMMI talked about it initially they had four levels of reform and they steadily went up the ladder until I get the real fixed price contracts and you can speculate about well you got you got to get to level threes and two level twos and three level threes and you can make judgments and that's fine about what you think it will take to get reform actually done but it seems to me that it's a perfectly fair question to ask to ask what is the actual numbers that we have today on level four level four in the CMMI structure okay is a fixed payment contract where there's no more money and we have had that in Medicaid but we have not had a dime of it in Medicare and we have not had a dime of it from the from the from private insurers so so I I think at a minimum we should be able to it should be knowable what is the actual number that is in fixed price contract you can interpret it any way you want okay my question is what's the fixed price number again I've got to break it down a little bit here I think that category four and going off memory is more like your Medicare Advantage type model where the commercial insurer gets a set amount of money they pay claims and that's it we don't have it we're not a Medicare Advantage plan so we don't have that level I think the closest piece to the true fixed price component is within our total value-based healthcare contracts as long as you're within that risk corridor that's a fixed price I mean you reconcile back to it if you agree the PMPM is 250 and it comes in at 260 you pay it back as long as it's within the risk corridor it gets a little complicated if you go outside and that because the payer does pick some money back up but within the risk corridor I'd say an aggregate for Vermonters that attribute all the 1.2 or 1.4 billion it's in that construct in some way or another the piece I think that you're getting at him is more of the the Medicaid fixed payment for example which is a true cap payment that we pay to hospitals and primary care we get we get from that there's no more or no less money at the end of the day and if the actual healthcare would have cost a lot more on the fee-for-service equivalent basis there's no more money if it costs less there's no more or less money either so that Medicaid piece is probably what you're getting at that is exactly what i'm getting at can we say what that percentage what that number is against the against the universe that is my point it's the only place that I can see it working is in the Medicaid contract and not the whole Medicaid but the Medicaid contracts where the care is being given within network not out of network because a bucket for out of network that you can't control at all yeah but that's the number that's that's exactly right what is that number that is within Medicare where there's no more money within Medicaid the fixed payment is in the 180 million dollar ballpark I'm sorry I didn't hear that for Medicaid yeah it's about 180 million dollars thank you that's the answer to my question now I don't know what the Tom likes if I like this thank you okay Mike Fisher thanks my question is much more nitty gritty I think Tom I'm trying to looking at the the relationship between slides 10 and 11 the attribution slide and the cost slides I think you described that the dynamic for the cost slide was both the reduced attribution and reduced utilization can you pull that apart a little bit more you provide some numbers for reduced attribution but can you pull apart a little bit more what what the reduced utilization was it's I don't believe I said utilization if I did it was a mistake but really just the benchmarks that were set by the payers so when the payers get their actuaries engaged and come up with the estimated total cost of care that hold us accountable to it the numbers came in lower than what we anticipated some of that actuarial process in some cases we negotiate every year to change what's which services are part of our accountability and in some cases we add services in some cases we take out we took a few things out negotiated a few things out this year to help make the accountability a little bit more clean for our participants so there's a lot of moving parts that go into those payer targets and you know we try our best to understand all the ins and outs of them in the negotiation process but ultimately they're the ones who say here's the number that you have to live by so I did misunderstand you so so reduced coverage is the help I wouldn't say it that way I would say the services for which one care and its participants are accountable can change every year as as service lines are added or deleted that all follows whatever the payers doing and in some cases if we know there's going to be a big change a pricing change it's a lot easier for everybody to keep that out so we don't have to do back end reconciliations with with a pair okay so I think I'm now understanding that that the reduced cost let me just try and say it tell me if I'm wrong the reduced cost on slide 11 really is driven by or is it substantially driven by the reduced attribution I would say it's a little bit of a mix in Medicare yes Medicaid no commercials probably yes attribution came in a little bit lower than expected or maybe a both there so there's a number of moving parts that go into those total cost of care estimates and ultimately where they land is just when we compare them back I mean sometimes they're high sometimes they're lower doesn't affect actual coverage or or or cost even it's an accountability measurement of here's a target that we're setting and our job is to be measured against that and be it okay thanks okay Walter Carpenter thanks Kevin a nice presentation I want to say thanks to Mike Fisher and for what he said and as a patient I can tell him and everyone that I go through that every time I go to the doctor's office duplication of services constantly you know you go into a specialist and you go through the whole information thing all over again and then so they can bill you or bill your insurance I even called them on at one time so that that's just typical the second comment is I'd love to be on that passport she were talking about as a patient because we're the ones that pay or paying the tabs for this and the third sort of overall question comment I'm not sure is I've been listening to the budget presentation and everything and the great questions by the board members which and Mike and Tom as well which I've been and Pam who's been fascinating is I'm just curious what has one care done for the health care of Vermonters I mean overall you go into the doctor's office they rush you through you know it's a wham bam bam thing what I mean that's just a small sample you're still dealing with multi-layers of private public insurance without Michael's legal aid department I would have been screwed just by costs and you complain to somebody and they don't listen to you so I have to go to legal aid because the word legal in front of it that's the only way they listen to you in the first place so I'm just curious kind of backing up Pam's question here is what has been done by one care with all this and Medicare and Medicaid payments is access to health care any easier I have a couple thoughts that I'm happy to share I think you know one thing I think that we do is that's important is trying to support providers it's a little bit of the Richard Branson philosophy is that if you take care of your employees they'll take care of your customers part of our job is to take care of the providers and make sure that they're receiving what they need to do a good job and then that translates down to better care I think that's important to note I mean the country that following Medicare's lead is moving to a value-based health care system and we're trying to help them with that honestly to make sure that they're able to make the transition and succeed under the model so I think by helping the providers it's a hope I hope it helps the actual patient care and that comes through data that comes through some financial resources that comes through being in a program that counts as an advanced alternative payment model through Medicare and gets them allows them to alleviate the burden of mits or things like like that so I think that's an important one the second one is tougher to like actually show it tangibly but I can say in the four years I've been at one care there is more talk now about the concept of population health and we're talking now about coordinating care more effectively that's taking time to evolve as one would expect but just the tone of what I hear from the providers is has evolved an awful lot over the last four years and I am very hopeful that over the next four years that starts to make care feel differently for Vermonters and you know it's tough to make such a big change across a whole state if we had 5,000 lives we could probably make a difference tomorrow but with so many lives it's going to take a little bit longer to make you know the kind of changes that we all want to see but that's a big one and I wish it was more visible but I certainly get to see it in my in my room yeah I would agree with that Tom and the thing that I'd also like to add is I think it's always important to understand what problem the ACO is trying to solve and the problems that the federal government has said that we need to solve is that payment incentives aren't aligned so it goes back to those things you were talking to Walter about having to go into your doctor's office because that's the only way that they get paid right is if they see you in person and ask a series of questions it might not be sensible for either one of you to use your time that way and the other thing is that care is not well coordinated because the payment incentives don't encourage providers to work together in a coordinated way so those are the two problems that we're trying to solve as an ACO and that requires providing some direct supports and resources and major shifts to the provider's office to be able to meet to meet those goals okay we're going to go to Rick Dooley thanks so much I just want to comment on Vicki's statement about the important importance of investment in primary care yeah we hear about risk sharing and and I think everyone agrees that it needs to be some rich shared the problem with primary care sharing risk is we're already so underfunded as it is and barely holding on that risk puts us at risk of closure especially independent primary care um and for shared savings to work for us to have you know to share risk we have to be able to really make an impact and we talked with us a couple weeks ago I just want to shout out to Vicki to say you know absolutely making those investments in primary care so that we can comfortably take risk but also take risk on the things that we can impact on so risk on total cost of care when we're such a small percentage of care is really really difficult risk based on our individual performance measures or ability to get folks into cscopes or or you know bring hypertension diabetes into better compliance absolutely makes sense and improve the whole population so so just a shout out Vicki that uh absolutely investment in primary care please okay we'll go ahead and go back to Ham Davis thank you Kevin uh the I appreciate from Tom Boy is the 180 180 million dollar number it's really a hard piece of information my follow-up question would be actually for both one care and for the Green Mountain Care Board that is the numerator what is your denominator the two choices it seems to me are the total number that total dollars that flow through one care which is I'm not sure I'm right about this but one point something billion or is the bottom is the denominator supposed to be roughly the total acute care cost which is around 2.75 billion I think and I think that the it's important to know which is the which is the denominator because it will drive it can drive strategic planning and action by the board uh thank you stamina I mean I think it it kind of depends on the what you're trying to answer or say I mean I would say it wouldn't make a ton of sense to use the total all-payer model healthcare costs for our monitors because a lot of that's out of state and unless we really became more of an insurer you know paying fixed payments to out-of-state and the providers this isn't isn't realistic so I I think a denominator to consider would be of the 2.5 billion how much is in-state and in a you know in a value-based healthcare participate in a value-based healthcare program that's one way to think of it another way to think of it is I mean our our fixed payment program is primarily hospital-based we do have the CPR program for independent primary care but to look at the 180 million out of the hospital spend is a pretty reasonable way to look at it too if we're trying to figure out what percentage of hospital level care is under a capitation model that doesn't reconcile and then the third would be to use the 1.2 billion dollars that's our accountability based on what we currently have contracted today so depending on kind of where you want to go I'd say those are three options to consider do you have a choice Kevin board have a choice in I think we'd have to have that discussion here I don't want to speak just as one member thank you I'm done okay but if I could just add to a kind of the tail end of Ham's comment my guess is that the 180 million dollars doesn't factor in the cost shift and so you can have fixed a fixed payment but it's only for a portion of the cost and I would think this is just a kind of a quick thought that if one care were successful in in mitigating to a degree it's with its in its negotiations with the state on Medicaid to begin to mitigate the cost shift obviously it can't be done all at once but but a progress forward that they would have an easier time addressing but Dooley's concern about and your strategic report strategic plan of increasing the proportion of independent primary care practices in the true capricated program if if the capitated program makes progress toward unwinding the cash uh cost shift then I would think more independence would want to jump on board because they get paid more they get paid more fairly and the other the other thing I would just add to this is I do urge people to go read um and this is maybe in response to Walter go read that march I think it is the March 7th Vermont Digger article by Emma Cotton about uh the success and one care being a part of it down at a southern Vermont hospital um it's it's quite a story and the impact is significant where um outpatient inpatient at one point was 80 percent of their case load and now it's down to under 20 percent they've really according to that article uh transformed their delivery system and uh one care was an important vehicle for helping that happen thanks Tom I have read that and I've read all the articles on Digger about one care okay is there other public comment and Marissa I I'm assuming there's no action needed by the board at this time that is right there's no action I'll I'll make a quick note about um timeline which I didn't meant at the beginning um we don't have a set timeline as as people know who are involved in this process we are also in the midst of the FY 21 budget guidance development which we'll be presenting on in June and so um when we are through our staff analysis of this revised budget that will either be scheduled to come before the board or communication may come to the board through memo which is how we sometimes provide updates on monitoring and reporting but no action at this time thank you Marissa and thank you um Vicki and Tom and uh you know we're we keep rowing in this boat and hopefully we get to that other shore so um is there any old business to come before the board is there any new business to come before the board is there a motion to adjourn some of second it's been moved by uh Jess and seconded by Robin to adjourn all those in favor signify by saying aye aye those opposed signify by saying nay and as a reminder to the board we have a meeting that starts five minutes at the conclusion of this meeting on a certificate of need discussion so thank you everyone have a great day thank you