 Good morning and welcome to the Green Mountain Care Board meeting. My name is Kevin Mullen chair of the board and we're going to start this morning's meeting with the executive director's report. Susan Barrett. Good morning. Thank you Mr. Chair. I have one announcement in addition to our calendar and that is on Friday of this week December 18th. We will be having a board meeting starting at 118. 11 a.m. The topic of the meeting will be FY21 ACO budget discussion and that will be posted on our website momentarily if it hasn't already. Thank you. Thank you Susan. The next item on the agenda are the minutes of Wednesday December 9th. Is there a motion. So moved. Second. It's been moved by Maureen and seconded by Jess to approve the minutes of Wednesday December 9th without any additions deletions or corrections. Is there any discussion. Hearing none. Those in favor of the motion signify by saying aye. Aye. Aye. Those opposed signify by saying nay. Let the record show the motion carried unanimously. So the next item on our business this morning is a discussion on the Medicare benchmarks. I'm going to turn it over to Sarah Lindberg to lead that discussion. Sarah. Good morning. Please allow a moment for the sharing to start. And I can see it. I'm usually the last one to be able to see it. So are there seeing that. We are. Wonderful. Okay good morning. My name is Sarah Lindberg. I work for the Green Mountain Care Board and head up the data team. And I come before you to for a recommendation on a proposal for the 2021 benchmark for the ACO participating in our all-pair model agreement. So just to level set there are different financial targets at play when we're talking about the all-pair model. Today we are not talking about those that are in the all-pair model agreement. That's a statewide agreement between the state of Vermont and the Center for Medicaid and Medicare Services. And that is a growth target between 2017 and 2022 between the range of 3.5 and 4.3 percent. So that's a whole different cookie that we're not going to be munching on today. Today we're going to talk about the Medicare participation agreement. So this is a contract between Medicare and the ACO. In our case we have one which is one care Vermont. And our job under the agreement is to set annual prospective targets also known as benchmarks for the spending of the beneficiaries who will be attributed to the ACO in 2021 or whichever year we're talking about. So benchmark we use that word a lot. So this again is the ACO's financial target for what we call a performance year or PY. There are five performance years in the Vermont all-pair accountable care organization agreement which I will call the agreement or the APM agreement. And again that is between the state of Vermont the whole state and the Centers for Medicare and Medicaid Services or CMS. I may also refer to them as CMMI which is a subunit for innovation under CMS. According to the agreement the GMCB each year must propose these benchmarks before the performance year starts so they're prospective in nature. And CMS might may either approve our proposal or request provisions. Again these targets are contractual agreement between the ACO and CMS. It's not the 3.5 percent that we talk so much about in the agreement at large nor is it the all-inclusive population-based payments or AIPBP under the Medicare agreement. Can I pause you right there Sarah. I did receive a text from someone saying that they're not saying the slides. I'm seeing them quite clearly. Are others having trouble seeing these slides. Not here. I can't see them. I'm fine. They are also available on the website if that helps that individual or I could. Yeah if they could just go to the website it's got to be a problem on there and so. You know what we'll share the link to the slides on the website in the chat. Thank you. Okay so the AIPBP or those all-inclusive population-based payments are totally different than these financial targets in the benchmark. That is not necessarily true for the Medicaid program so just remember that Medicare is a different animal than Medicaid. So the AIPBP for Medicare is a means for making the revenue more stable and consistent. And essentially what happens is for people who elect to get these prepayments the federal government looks at what Medicare has historically paid that provider for a year and tries to divide it up into 12 equal chunks for the whole year and that makes the revenue more consistent and stable. However those payments will be reconciled to the actual care that was sought by the people attributed to the ACO. So they see what care the provider actually did provide and figure out what Medicare would normally have paid under the fee-for-service business as usual schedules. So those reconciled amounts are the ones that we are talking about when we're talking about the ACO's total cost of care or otherwise known as their financial performance under the model. So as you can see 2020 had quite a big difference between that AIPBP the top line and the fee-for-service equivalence. So some of this between March and September a good reportion of this will be luckily eligible for reimbursement through the stimulus funding. But under a normal year this is exactly the kind of risk if you want to call it that or reconciliation that might be of concern to providers. They would rather not have to worry about paying this money back. And that's in fact why Medicaid is different and likely more attractive to a lot of providers. I will say that this is incurred through August and paid through November. But as you can see that little bit of a nosedive between July and August that is because UVMMC was not able to submit claims due to the cyber attack. So we're still waiting for them to catch up. So everything we're looking at is a little bit distorted. Normally three months of run out we would feel a lot more confident about. But we're just kind of waiting for them to catch up. So as far as the agreement between Medicare and one care one care will have a total cost of care which is the actual spending that will occur for beneficiaries who are attributed to them for the performance year. So what happens is we figure out all the fee for service payments that Medicare makes for those folks. And then we figure out the amounts that were prepaid through the AIPPPAIPBP first to whoever came up with that acronym and just rolls off the tongue. So again this means that you know even though I'm attributed to one care because my primary care relationship appeared to be in Vermont any care I were to receive in New Hampshire or Florida or any old other place that Medicare pays for is going to be included in there. So it's not just the care delivered by the ACO. The prepayments through the AIPPP would only be in the network because they're the ones who elect to be paid in that way. So what happens is they figure out how much the ACO has beneficiaries spent. Compare that with their financial target and that's how we determine whether the ACO is eligible for shared savings or losses. It's important to keep in mind that this comparison only happens at the ACO level. Any reconciliations underneath that are the ACO's responsibility. So how they distribute that through their network is not what Medicare is up to. Their relationship is at the ACO level. And so here's an example benchmark. So in this case if we said the target for spending was $100 in the middle you see that risk corridor. In this case it's a plus or minus 5% but that could be any approved amount of risk. And so if the ACO spending was 90 the ACO would get the $5. Between 195 and CMS would keep the additional $5. If the ACO's spending was $105 they would owe money back to CMS to get to $105 and CMS would have to pay out that additional or if it were $110 sorry they would pay that additional $5. So there's a risk corridor. If the ACO performs really, really well the Medicare payer would keep that additional benefit if they perform really, really poorly there's some additional protection where Medicare would step back in. And so and I'm looking at slide eight now for those of you who were unable to look at it online you can see the ACO's performance in 2018 and 2019. It looks like the labels are cut out I apologize for that but the target in 2018 was $339 million. The ACO's performance was $322 million. So they had savings in that year. In performance year 2019 their target was $496 million and the ACO's performance was $484 million. So they again achieved shared savings in performance year 2019. So as a reminder I came before you a couple months ago to talk about the 2020 benchmark and at that time the board unanimously voted to amend its proposal for performance year 2020 midstream due to the repercussions of the public health emergency posed by COVID-19. And as a result of that to take a page out of one I'm sorry the larger shared savings oh gosh next generation ACO program they're using a retrospective trend. So they're going to see what actually happens to expenditures between 19 and 20 to kind of make the target reflect what's happening statewide. The major win I think for the ACO here is that it did allow for some additional financial flexibility for Medicare. So during the public health emergency there is no downside risk to ACOs and it also removes any costs associated with COVID episodes from their total cost of care. So they are not on the hook for those expenditures. And so what we do to figure out that trend is we look at all the Vermont residents who would theoretically be eligible to attribute to the ACO and we look at what their expenditures were in 2019 and we take a look at that same population of people who could attribute to the ACO in 2020 or eligible for attribution to the ACO in 2020 and see what their expenditures look like. And again, encourage through August and pay through November knowing that we're missing the UVM claims. That trend right now is negative 13 percent. So that's a substantial decline between the performance years. I'm sure that's not news to anyone here that our providers are feeling that. So the only way I could think of to try to distill 2021 is a quote from Winston Churchill which is it's a riddle wrapped in a mystery inside of an enigma. So we have a lot of extreme uncertainty heading into 2021. The pace of the recovery, the potential effects of care that's been deferred during the pandemic and any costs associated with vaccination are very difficult to predict at this time. We are sure that expenditures in 2020 will be well below a typical year, which means that the growth between 2017 and 2020 are almost assured to satisfy the goals of the all-pair model agreement. So it's possible that the access to quality care and providers may be more concerned when thinking about 2021. And I also think that this is a good time to try to take advantage of the very tangible benefits of the predictable and stable payments such as the Medicaid program provide in thinking about expanding some of the delivery reform that is currently underway. So when thinking about the 2021 benchmark, the proposal would be to replicate the amended 2020 methodology for 2021. So that would mean using the actual claims experience for the full statewide set of beneficiaries who would have attributed in 2020 or were eligible for attribution in 2020, compare that to the same set of folks who would be eligible for attribution in 2021 and use that as the trend rate in the benchmark. We would actually, for the base experience, we would wait until we had three months of runout and see for the individuals who would have attributed to OneCare in 2020 based on the 2021 benchmark what their costs were in 2020 and see what that trend looks like. We also know that this would have the advantage of extending the PAT protections to the ACO which means continuing to remove the COVID episodes from their total cost of care as well as eliminating any downside risks during the public health emergency. So the benchmark essentially has three components. So starting from the last, the historical experience, again, that's where we would take what the Medicare medical claim spending was in 2020 for beneficiaries who would have attributed to OneCare in 2020 if the 2021 network had been in place, take the number of people who will attribute to the ACO for 2021. So the prospective number of people who we know will attribute based on their primary care relationships and then using the trend, which would be the actual change from 2020 to 2021 for all Vermont Medicare beneficiaries eligible for ACO alignment and that would set the financial target for 2021. So the tradeoff here obviously would be that the actual benchmark wouldn't be known until after the fact, but given all the uncertainties that might not be as bad a deal as it might be in other times. And I'd like to conclude today by just giving you some background on the advanced shared savings component of the benchmark. So the advanced shared savings are a mechanism to help extend some investments to some Vermont programs. The primary care medical home payments, the community health team payments and the support services at home payments were once funded through a federal demonstration called the multi-payer advanced primary care demonstration practice demonstration and that ended in 2016 and along with it the federal funding that came. So the agreement included some provisions to allow the state to continue funding those programs particularly because they demonstrated savings to the federal government. But it's important to know that these funds are added to the benchmark and they do not represent performance risk. The advance does factor into the reconciliation at settlement, but it's not additional performance risk and what I mean by that is the benchmark that I was talking about earlier is the financial target. That is where the ACO's performance is really judged and then there's this addition of the advanced shared savings reconciled at settlement that has historically been used to fund, continue the funding of these programs with some federal dollars. So just to give you an example, here's a shared savings example for a Medicare settlement. So in both cases whether or not you have the advanced shared savings, that performance benchmark, that first set of the benchmark equation would be $400 million in this made up example and then if you were to include the advanced savings you could add on say 8 million which would mean that the total benchmark is increased in the in the advanced savings model at the 408 million versus 400 million without the savings. And so either way the ACO's total cost of care would come in at 395 million. I just made up a quality withhold of $200,000 and here's where it gets different. So the gross savings that the ACO would see with the advance is 12.8 million. Without that the gross savings are 4.8 million. At that point they take into account what was already paid in the advance. So when you deduct 8 million from the 12.8 you end up in exactly the same place. So in both cases the ACO has saved $4.8 million. So again that performance risk has not changed. In an example where there's a shared loss so again we have the same financial benchmark target of 400 million. We add in the 8 million but if the ACO's total cost of care were 405 million and we still deducted the $200,000 for a quality withhold you can see with the savings they actually have I'm sorry when they include the advance saving there actually is gross savings of 2.8 million dollars which actually net a loss of 5.2 million. Again that's mathematically the same as if there had not been advance savings. So in both cases the performance risk that the ACO would be on the hook for 5.2 million dollars back to the federal government. The difference would be in the advance savings example they theoretically would have also paid out 8 million to providers to support those programs. So their liability would be you know 8 million plus 5.2 million. So I just want to be clear for board members that you know that this is just a mechanism by which the federal dollars are able to be leveraged for this purpose but really that this is a decision for the ACO budget. In the past the Green Mountain Care Board has set a minimum amount for the ACO to invest in these programs in their budget order and I would say that for 2021 the ACO budgeted 8.4 million for those programs and it was the same amount that they budgeted in performance year 2020. So you know I think that the ACO appreciates having this to help fund this and not come up with that that money ahead of time if they are ordered to make that investment but the decision really rests with the budget order. And that was all I had today I'm happy to take any questions. Super thank you very much Sarah. Are the questions from the board. This is Robin I had one question. Sarah so when you were talking about the 2021 benchmark and some of the advantages given that we're still in the middle of the public health emergency you noted that there would be no downside risk during the public health emergency. What happens if the public health emergency ends prior to the end of 2021. We'd come back and revisit it or do you have any ideas of how that might work just thinking ahead. Yeah absolutely I think the main variable there is you know if the public health emergency were listed in March I am sure that our federal partners and us would come together to amend this proposal to go back to a prospective target for the remainder of the performance year in the case where you know it kind of bleeds into you know more than half the year. I think our recommendation would be to you know remove some of those protections but keep the methodology the same I think the methodology does make downside risk pretty unlikely just given that it's it's scaling to actuals but that explicit protection would be removed I would assume. Thanks and then I'm assuming because this is a contract with Medicare that Medicare would be using the federal public health emergency declaration not the states or do you know that's correct yeah okay yeah we're following the federal definition. Okay thank you. Thank you Robin are there other questions or comments from the board. I have one just the the whole advanced sharing savings is before my time like Robin understands it but to me the way I interpret that is that it's just a mechanism to finance the distribution of those funds to you know to blanking on the name of the organization out there the blueprint for example and so is that all it is is basically a way to you know kind of fund it a lot kind of a no interest loan for a year and it settles up at the end of the process and if so why did that happen in the first place. Sure so as I understand it there were only two possible ways for this money to come to the feds for this purpose. One was used in 2017 and I never remember the proper name but it essentially was a grant that was bestowed on Diva and distributed through Diva for this purpose and the second way is through these advanced shared savings which were kind of a creative mechanism to allow this and the reason for it is that the process but that was used in 17 required a clearance through the powers that be up at Medicare and frankly takes a long time and makes the funds more vulnerable whereas this decision really keeps it in Vermont's control. Thank you. Makes sense. Okay are there other questions or comments from the board. Is there public comment. Public comment or questions. Well a very silent morning. Sarah what are the next steps. Sure I will I'll be I'll see you again this afternoon but I'll also see you again next week for a potential vote on this recommendation. And do we have a public comment time period. Oh certainly that would start now through next Tuesday. Okay one last chance for anyone to offer any public comment or questions. If not thank you very much Sarah. Good work as always. Thank you. Talk to you later. And next we're going to turn to Green Mountain Care Board Payment Reform alum and a former leader of a Vermont hospital. Our old friend Richard Slusky and Richard maybe you could introduce your colleague who's going to join you in the presentation. Yeah can you hear me Kevin. I can I can't see you but I can hear you loud and clear. I'm having trouble turning my camera on. I had it on originally and then turned it off and now it won't go back on. So is that just because you didn't want to wear a tie Richard. I actually almost did Kevin but you know I can't go that far. Okay um let me try to share can I try to open the slides for you. Make sure I can do this. Can you see that. Not yet. Now. I know. Okay. I'm wondering if you want to send them to Abigail and maybe she can. She has them actually. Maybe that's the best thing to do. Abigail are you available to assist. I got it Susan. Oh is that Michelle. And Chair Mullin I was wondering I know we're gonna we're going to hear from Richard and his colleagues but Michelle DeGree was also going to have a few words before he started because Michelle DeGree and Lindsay Kill worked on this project with the NESCO team. Is that okay. I was assuming that was going to happen but it was not on the printed agenda so I I tend to follow the script so I don't get into trouble. But Michelle take it away. All right just to confirm can you see my screen. We can. It's a nice blue color. It's very blue yes. It's really casting a delightful shadow on my face. So I just wanted to give a couple of quick remarks as Susan mentioned. Lindsay and I were able to work with On Point and NESCO throughout this process but then oh gosh Richard probably over a year at this point since our last meeting in 2019 and then we had a virtual meeting obviously in 2020 of the group and we were able to work and produce some data that's used in this first of its kind comparison of primary care investment across 6 New England states. I will say I just wanted to point out a couple of key points for the board and for others that this report in and of itself will not match with what we've produced for our total cost of care reporting nor with what we reported for our Act 17 primary care spend report as requested by the legislature. And part of the the main reason for that truly is that when you're looking at six states finding a common denominator means that you're going to lose some of the data that we are lucky enough to have access to here in Vermont. So I just really wanted to preface that and while you're when you see some of the great data that's going to be presented by Richard and I believe Carl and Caroline are on from On Point but I'll let them introduce themselves as I want to just make sure that it's clear that you know we are aware that this doesn't match and I think we'll try our best to kind of make those comparisons moving forward when when folks might reference this report or even try to put together maybe a one pager of kind of how these things differ between our our typical annual total cost of care reporting and this report here focusing specifically on the six states and not to get ahead of Michael's but I think or to get ahead of Richard but I think once we kind of get through the slides you'll hear a couple of recommendations that the workgroup might have for additional analyses or moving forward and Lindsay was really pivotal in helping to frame some of those so I think if there are questions on the board I believe Lindsay and I are both on the line and can stick around to answer any questions that you might have and I'm hoping this kind of sets up a nice conversation for your panel discussion this afternoon so with that I will get over to Richard and On Point team Richard if you just want to let me know when to advance I can do that for my end okay thank you Michelle and you can advance the slide so as as Michelle mentioned this was this study was made possible through the collaboration of the six New England states including Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont and it was sponsored through the New England States Consortium Systems Organization, NESCO and a contract with On Point Health Data and we have I believe with us from On Point, Carolyn Conrad and Carl Finneson who were very instrumental in helping us develop this report along with Katie McGraves Lloyd and Jeff Spalding from On Point. Next slide. So I just I also want to recognize Michelle and Lindsay for the work that they did on the project and also Sarah Lindbergh who I believe behind the scenes did a tremendous amount of data work so I want to thank thank you all for for your effort in this regard. Next slide. So the as as Michelle mentioned this project has been kind of in development for over well over a year I think it's probably closer to two years but we were very encouraged to see the primary care collaborative which is a national organization actually include in its consensus recommendations that the importance of tracking primary care investments through a standardized measure and this the purpose of our report was to try to get the states the six states to agree on standard definitions of who primary care providers are and what services are most commonly provided by them that we could universally agree upon and that that approach we felt was reinforced through the consensus one of the consensus recommendations from the primary care collaborative in 2018 and that this this approaching this from a standardized approach was really necessary in order to track the level of investment and also that these increases in investment might lead to improve quality. Next slide. The purpose of this report specifically is to use that standardized data to identify the percentage of all-payer primary care spending relative to the overall health care spending in each state and that that's really the primary purpose of the report. What we did not do and what is not included in this report is a statement about how much investment is the right amount or how what are the measures to evaluate the impact of those investments on cost quality and access in the health care environment. So if you're looking for the golden nugget that says this is the right amount you won't find it in this report that does go beyond the scope of what we intended to report. Next slide. So just to give you some background there's no national standard on the measurement primary care expenditures and we looked at several studies that have come prior to this study and none of the studies use the same definitions in total. They're close but not what we've used in our study. As I mentioned it's 6 New England states included about 7.2 million dollars 2 million members in commercial Medicare Advantage Medicare fee for service and Medicaid members. It's the first to our knowledge the first multi-state report using standard definitions of providers and services. We did not include OBGYN providers in the definition of primary care providers but we did report on OBGYN providers and services separately in the report. We did not use some providers that are sometimes considered as primary care such as naturopaths homeopaths behavioral health providers were not included in the study and the information regarding non-claims payments or value-based payments was collected directly from payers. That's not information that's included in the APCDs in the state states. Next slide. So just to give you there were four definitions. One was the primary or core definition which were the definitions of primary care providers including general practice family medicine, pediatrics, total medicine, nurse practitioner and physician's assistants and some subspecialties in each of those categories. So geriatricians for example hospice and palliative care providers were also included. It did not include OBGYN providers or services and the services were limited to a selected number of services that were limited to those most commonly provided by primary care providers. Definition two are the same providers excluding the OBGYN services but the definition of services is broader and that includes all services provided by those providers. So it's a broader definition of the services but the same definition of providers. Definition three were the OBGYN services payments for the OBGYN practitioners and that included in this case services provided by primary care providers. That definition if states want to include OBGYN they can add that to either definition one or two or both to get a sense from their perspective if they want to include the impact of OBGYNs they can do that from this study. And then definition four were OBGYN services provided by primary care providers. Next slide. For the non-claims expenditures or the value-based payments we did develop on point developed a template to collect the non-claims payments. I'll show you that later on but it includes services such as capitation payments, risk-based reconciliations, PCMH payments, provider incentives, HIT payments for health information technology improvements, and then workforce investments. Next slide. So the strengths of this study in our opinion were that all of the states had existing APCD data to generate most of the required data so that was very important that the states could actually produce the data. We also used what we call a distributed model which means that rather than hiring one consultant to go into each state into each state's database and pull the data from the state's database we instead developed specifications based on the definitions of providers and services that we had generated and on point developed specific specifications which were given to the states and their analysts in each state were able to pull the data and the summarized reports formats that that we were requesting. So this this actually was a less expensive approach for one and it also allowed the states to become more familiar with the data specifications and this specifically the data as they reported it back to on point. The specifications and the data definitions were those that were read upon by the six states and then kind of supplemented through discussions with on point and NESCO but ultimately it was NESCO that determined the final specifications and then there was a robust quality control process once the data was reported. So we're pretty confident that the data is reliable and in good shape from the states. Next slide. Some of the weaknesses were that not all the states had complete data for Medicaid and Medicare. We did not evaluate the reimbursement rates or benefits by payer as part of this study. So and there is variation as you will see by comparing payer to payer and also state to state. So taking an average of any of this data you know for a specific purpose might not be a good idea. You may want to look specifically at your state's data and then the payers within the state specifically. The non-claims data as I mentioned was not reported through the APCDs and needed to be collected directly from payers which proved to be somewhat of a challenge. Pharmacy expenditures were not sufficiently reliable to be included in the report and the impact of the pharmacy rebates was not determined and we had a discussion yesterday actually in a meeting where it was reported that those rebates are very significant. So to report the expenditures of pharmacy from the APCDs without taking into account the rebates may lead to an overstatement of the pharmacy expenditures. And not all of the states were able to link membership. I don't know if you all can see that. I'm having it blocked by my tray here but we weren't able to link member eligibility to medical claims or pharmacy benefits. We did aggregate by payer the number of members and member months but we couldn't do a specific link on individual members. Next slide. You're all hearing me I assume. Yes. Okay. So let's get into some of the results. Next slide. And this is on the claims payments. So you can see in this figure one this is a by payer for the definition one and two. It's definition one again being primary care providers with selected services definition two primary care providers all services. And you can see that there is significant variation by payer as a percent of total health care expenditures with Medicare and Medicare fee for service and Medicare Advantage being on the lower side as a percent commercial and Medicaid being on the higher side. On average in the blue box over on the left 5.5 percent of total payments went to primary care using definition one and 8.2 percent using definition two. Next slide. So the next slide is the per member per month payments which is which actually kind of caught our attention because if you notice here Medicare fee for service and Medicare Advantage are actually higher on a PMPM basis than Medicaid or commercial and that's true for both definition one and two which we think we believe indicates that older individuals require more primary care services even though the percent of those payments as a percent of total health care costs are lower the actual services received by older individuals primary care services are actually higher or are more costly. So on a PMPM basis you can see that Medicare fee for service and Medicare are higher than either commercial or Medicaid which was an interesting observation we thought. Next slide. So this is by state and you can see that there's variation and again definition one and this is commercial payers so you can see that there's variation not only by by what you'll see there's variation by payer but also by state. So again and again I don't know if you can see the state numbers on the bottom mine is cut off so I'm sorry for that. Can you see those Kevin? Yes. No you can okay. Yeah you might have your screen enlarged a little bit if you just uh yeah I'm trying not to touch any button that I don't okay so anyway you can see I'm glad you can see that but you can see that there's variation by state and then you'll in next slide you'll see by payer as well. So this is Medicare Advantage and again you know and also within the state there's differences in terms of the payments the percent payments from by payer as well. Next slide and this is true for now we're on Medicare fee for service so again you know a lower or well not so much a broader range but it starts lower for Medicare fee for service as a percent and this is a function when you're looking at Medicare as a percent of total health care expenditures for Medicare as you get older you're using more hospitalizations more specialty services etc so you would expect that the percent of primary care payments are lower and then next is Medicaid I believe. Next slide. So Medicaid again you know difference in in by state and there's a difference in the payer as well for the average here is about a percent and then 10.4 percent for definition too. Next slide. So this kind of summarizes this if you look at the all-state average for commercial Medicaid Medicare and Medicare fee for service as a percent you can see that the different payers have different percentages and then again if you look at the PMPM and this is definition one you can see that the Medicare Advantage and fee for service has a lower percentage but a higher PMPM. So I just want to highlight those for you and that's true for definition too as well. Next slide. So you can see again you can see that while all the numbers are higher the Medicare PMPMs are higher than the commercial and Medicaid and I'll get into a discussion of why that it's important in a second. Next slide. So we also looked at these payments by age and these are all payer percentage payments by age group for definition one and you can see that the payments as a percent of total are much higher for younger or children in particular and then younger adults and then they decrease as one ages and this again is a percent of payments relative to total healthcare total medical payments. So children you know generally have more primary care visits than they would other hospitalizations things like that as you get older you're using more specialty care and hospitalizations which reduces the amount of the primary care percentage. Next slide. When you look at a PMPM we see the same kind of relationship. So initially the younger adult the younger children you know just born or or one to four have you know the just born obviously that's the major component is the primary care and then it it dropped whoops did I so I think yeah so I want to be on the next one. Next slide. Yes. So you can see that it drops down and then the PMPM increases as the population ages. Next slide. So this this is where I think you know as we're thinking more about capitation and value-based payments other forms of value-based payments I would you can see that the commercial payments go down as a population ages as a percent of total in all cases and the the PMPM which would form the basis of a capitation kind of has significant variation as you get older and then it kind of dips and then goes up again. So one of the things I think this points out to me at least and I think is consistent with some of the discussions we had when I was at the Green Down Care Board is you really have to take into consideration the mix of a practice when you're thinking about the capitation. So if you have providers who are primarily seeing an older population their PMPM may be in the 30s or 40s and you know if you've got a younger population it may be less. So it's just something to think about as we're thinking about moving toward more capitated payments. Next slide. This is the payments as a percent by service type and again just to highlight if you look just at office visits and preventive care you're at about 90 percent of all primary care services as a percent and then immunizations you're probably 95 96 percent. The ones in orange I thought were interesting because and I'm not sure I'm right on this but there's a lot of services transitional care management chronic care management advanced care planning that I don't believe are accounted for through claims. So for Medicaid for example I know a lot of money is spent on these types of services that do benefit primary care practices but are not really considered part of the payment to primary care services at least through claims. So I just thought I would note that that this might be an area to really take a little harder look at. I think even commercial payers often pay for these types of services through what they can I'm not sure if they put them in administrative categories but they they don't always include them in the claims. So we may be missing a good deal of investment in primary care that just isn't reported in a traditional way. So that's that's that's my theory but you know we can discuss that. Next slide. So on the non-claims payments next slide we we did have to develop a template that kind of identified the types of services we were looking at and I discussed this a little earlier. So you've got the capitation the risk-based reconciliation PCMA patients and we tried to identify to define them based on other studies that had been done so that there would be more of a standard definition on these payments as well. Next slide and then the others are provider incentives performance-based payments investments in health information technology and workforce payments. Next slide. So this is actually the template this just shows one category for capitation but this is what we would propose you might want to think about in when you're looking for information from the payers that you'd wanted to know how much are they actually paying in non-claims payments which is the third column. And how those are broken up into members and member months and then of that total how much of those payments are actually going or intended to go to primary care practices and again based on members and member months if possible. A lot of non-claims based payments are not made directly to primary care practices they're often made to health systems or hospitals that employ primary care providers so it's hard to determine exactly where these payments are going and I think we think that a more specific reporting requirements would be helpful in resolving that. Next slide. In terms of the collection of the data we only really could collect information on the commercial payers and only four of the six states were able to collect payment information regarding non-claims payments. So as I said earlier this study kind of highlighted the need to work with states and payers to track these types of payments in a more consistent way. I would mention I think this is correct that Vermont Medicaid is now paying about 80 plus percent of its total payments through non-claims based payments through prospective payments to the ACO. So this percentage in the blue of the claims payments for Medicaid would be much higher or lower I'm sorry and the green would be much higher which are the non-claims based payments. So if we're moving in that direction I think you're going to start to see overall that the blue bars starting to become lower the percentage payments and the green higher a higher percentage which indicates that we need to have better means of collecting accurate information for both claims and non-claims payments. Next slide. So in terms of the non-claims payments just to summarize reliability that payers weren't able to report the non-claims payment using these defined categories. It was not clear what percent of the payments were used to support primary care practices. The state analysts did provide estimates for us on what they thought was going to primary care but I think it really we need better data. And as I said they weren't necessarily directed to primary care providers or practices and may have been paid instead to hospitals or other health care systems and it's not known how much of that actually got to support primary care. And then the estimates of the total commercial payments that benefited varied from state to state. Next slide. Again just here at the bottom you can see highlighted in yellow. So you've got the total amounts of these payments but I think what's important to note is the primary care payments from claims by state you know range from 8 percent 10.997 but if you look at the impact of the non-claim which includes when you look when you total the two together the claims and the non-claims payments there's significant variation in the impact those payments have from a state to state basis. The expectation is that the primary care claim payments will decline over time as we move to more value-based payments and these value-based payments will have more of an impact. So again the importance of collecting good information on value-based payments or non-claims payments will be very important. Next slide. So the summary of this they're usually not reported to the states through the APCDs. It's anticipated to increase over time. Intent these payments of non-claims payments are intended to incentivize primary care practices to restructure their operations to support improved quality reduced unnecessary utilization and increase focus on population health. We're recommending that states may need to consider adoption of new regulation statutes or rules to standardize the way in which this data is collected the non-claims payment information. Next slide. So issues recommendations and conclusions. Some of the issues that we had to make decisions are whether one was whether or not to include out-of-state providers which we did include. So these are these payment amounts are based on allowed amounts that have been identified associated with residents of the states regardless of where their providers were located. In the APCDs there was no field or code specific to identify the site of where the care was delivered. So that's something that might be improved in the APCD. The defining primary care providers and services is critical. Linking to eligibility we think is would be a significant improvement in the data to make sure that we're linking members both to medical claims and to pharmacy claims as well. The retail pharmacy whether to include or not we did not include retail pharmacy and as it turns out I think that was a good decision given what we learned later about the impact of rebates. Plan paid or allowed amounts most of the studies that we looked at did use allowed amounts and that's what we agreed to do. Some use plan paid. Non-use charges by the way so I wouldn't we don't want to go down the road of using charges for this this type of an evaluation. We did not include dental and vision services there was some discussion about that and there the Medicaid non-medical service or non-medical services is something that I think we need to also look at further as I mentioned earlier because I think there may be there appears to be a lot of investment in care management care coordination etc and other types of services that that are not included in this kind of a study. Next slide. So policy issues for states ensure that all payers report claims payments to the APCD in a standardized format including Medicaid and Medicare to the extent possible. Consider rules regulation statutes etc regarding the reporting of foreign payers regarding the reporting of non-claims payment. Standardize a more consistent approach to reporting on Medicaid services and payments and look at approaches that incorporate the percentage of both total cost of care and per member per month. So this is that issue about percentage and the relationship between the percentage of payments primary care payments and the PMPM. Next slide. Some technical issues you know as investment in primary care increases payers are going to want to know what the value of those increased payments might be. So I think understanding or developing some measures to evaluate this association between the primary care payments and the level of those payments and performance outcomes is going to be critical. We were with COVID there's more remote care management now there is more remote care delivery. So I think we're going to need to understand the impacts of COVID-19 on on these payments and total health care expenditures. And then the pharmacy payments I think if we're going to incorporate that into these types of studies we need to understand the impacts of the rebates and better link eligibility to pharmacy claims. And then the evaluation of the these broader services that we used in definition 2 it would be interesting to know which of those services that were not included in definition one had the greatest impact on increasing that percentage of primary care payments to the total medical payments. Next slide. So just to conclude the study benefited from the existence of APD PCBs in all the states and also from prior reports on the topic and by the way I should mention that those averages of 5.5% and 8.2% of primary care relative to total medical costs was very consistent with the other state reports. So it was certainly in the ballpark for what we saw in other prior reports. Using a distributed model we thought actually worked pretty well and the states were extremely cooperative and just want to again thank Michelle and Lindsay and Sarah for the work that they did on this. The results are that investment in primary care was relatively low the 5.2 and 8.2% compared to total health air expenditures and we noticed the variation by payer geography age group and other factors. And again we're not suggesting that we know what the right number is here but we believe this is certainly when you're comparing to other countries this investment in the United States in primary care is relatively low. We've highlighted some opportunities to improve study methods to establish more consistently comparable results and I think the experience enabled us to continue our work together to improve our study methods and ways of looking at this data. So that's all I have. Next slide. But I would like to ask Carl or Caroline if she's still on if you have any comments that you'd like to add to this. Well this is Carl Finneson from On Point Health Data Director of Analytic Development. We were thankful for the opportunity to work on this project with the six states. Back quite a while ago we did a tri-state study for Maine, New Hampshire and Vermont data that was commissioned by the Deon Kahn from Bishka before GMCB and so we were always looking for an opportunity to expand that to the rest of the New England states so we're thankful for the opportunity to do that. Also just want to recognize the 30 or so people that participated in this project and for the efforts they made. We had a pretty rigorous review of the specifications. States came up with additions and changes so we modified specifications to enhance the reporting so it was really a collaborative effort and appreciate that effort and again to Lindsay and Michelle and all the other states for the quick turnaround. The specifications weren't created until June or July and then it was fairly quick turnaround for the states to produce the reports within a couple of months and then we get those into a written report and so it was quite a fast project but a thorough and enhanced specifications on the project as well from what we started with. That's what I had Richard. Okay thanks Carl. Thank you and thank you again for all the work that OnePoint did on this. We couldn't have done it without you. Kevin any questions or comments? I'm sure there's a lot of them Richard. I'll start with a few. You know when you're benchmarking Vermont against the other states am I wrong in in my quick read on this that we're doing okay in government reimbursement for primary care compared to our colleagues but maybe a little bit behind in commercial and also maybe you could comment on you know everybody talks about Rhode Island being way out in front with the legislation that required a percentage spend on primary care and yet it looked like at least far as government that they weren't doing much better than Vermont on that so I'm just curious what your what your take on that is and if it's fair to try to benchmark based on this study. Yeah I think I think and I'll let's see if Carl has anything to add on this but I would say using the word okay even is you know kind of implies something and we don't know what the right number is so I would agree that it does appear that Vermont is doing well you know better on the government side on the on the investment in primary care and could probably improve on on the commercial side. Rhode Island specifically focused on their commercial sell fully insured population so it's you know I think and I don't certainly don't want to speak for Rhode Island but I think their effort was really more on the commercial side to make sure to try to encourage the commercial payers to increase their investment in primary care and they actually at the same time put caps on the amounts that hospitals could raise their rates so they you know they kind of were trying to shift that emphasis from the hospital system to primary care so and and as as Michelle said earlier I think and Carl might want to add to this these numbers that in our report don't square specifically with the report you guys did earlier and there are some reasons for that I think either Michelle or Carl might want to address so Carl did you want to speak to that or Michelle? Sure I can speak to a couple of things first of all just going back to the Rhode Island so one of the things about the Rhode Island studies are reported data is that they don't actually provide any methods or specifications for how the data is created that it's up to the insurers to provide that data in and I know they they potentially include non-claims payments in that data as well so just a little caveat about Rhode Island information that comes out I know a lot of people point to Rhode Island because of the trend and the one percent increase in primary care each year concerning the Vermont specific results so commercial was on the lower end and of the states but Medicaid and Medicare was on the higher end in fact as as Richard showed Vermont was highest among the six states for Medicaid and second highest for Medicare and then lowest for commercial so this was a descriptive our work on this study was descriptive we weren't there was no intent to evaluate the causes of those variations so but that type of thing could continue to be explored you know we didn't adjust for age gender differences for example within the commercial population so there could be a number of different factors that that lead to these results or these variances that have yet to be explored but with Vermont having one of the older demographics wouldn't it be hard to say that that's a factor in the lower commercial spend yeah the when you talk about the percent it's it's also related to the denominator as well so if there's a if there's a higher denominator if your total medical health care expense for a commercial is higher in Vermont then that could cause your percent to be lower as well okay one of the recommendations talked about requiring better reporting so that's more standardized and of course Richard as you know we always are getting hit by your former colleagues about whether or not the the juice is worth the squeeze and they keep talking about the administrative burden are you convinced that it's worth that additional burden to them or is it really a burden to them well I think it is worth it because I mean I don't I think what's what we're going to see going forward is more and more emphasis being placed on I mean if you adopt the Medicaid approach to to these payments you know you could be in the 80 85 percent of non-claims payments and if you can't really identify where those payments are going and and then ultimately develop measures to evaluate the impact of those payments on reducing costs improving quality improving access I don't know I don't know what you know how how you would justify you know that shift I mean because because the theory is if you move to value-based payments or non-claims payments there should be some impact on the system so I yes I think it's worth it and it will always be value-taking you know around any change and I think you know I think it's worth also evaluating the measures that are currently in place and whether they're producing the results you want so if there's a trade-off to maybe reduce some burden in one area where and if you think it's it's more valuable in another I think that's a reasonable discussion to have. On your discussion of what to include and what not to include in primary care that's been a hot topic for a number of years without much general agreement and it almost looks like here there still isn't general agreement it's just that it was agreed to do the reporting the same way for the comparison but for example you often hear that you know for many women their gynecologist is the only medical person that they're visiting and yet it's not included but it's collected here I was just curious if you ever think there will be a common definition across the country for primary care. So this this was a big discussion that we had you know in in the group and the approach we took was that those discussions have continued on and on I mean there were people that think OBGYN should be in I know that you guys require naturopaths I believe to be included in primary care and and others homeopaths behavioral health would like to be included so what we tried to do was say let's let's try to agree on a core definition of providers and services that we can all agree on I mean you know and then if other if state and and get a base report so that's definition one in effect that that's the definition of providers and services definition two broadens that to include more services but same providers then if states want to add OBGYN or they want to add naturopaths you can see the way we did it was to separate those services out and and and add them on to the core definitions add them on to your results so if you get and by the way I mean when we added OBGYN when we had I don't think I showed that but when we evaluated the impact of those services and those providers on the total percent it was less than one percent you know and that was for OBGYN so so I think I think in this case I would say it's not worth having this discussion that you never reach agreement on but you could agree on a core and then and then allow the states to add to that core as they see fit on your slide that showed the PMPM by age category that the number the dollar number went down for 85 plus any insight into why that goes down uh trying to find that one um well it didn't it did for 85 plus on the PMPM yeah this isn't the one I'm thinking of Michelle it's the one that had the um because it's actually I've got around 36 dollars on the okay right here you've got 85 plus at 29 24 um for commercial which um is lower than yeah yeah than the uh and even on the Medicare it's down but not not much from the 75 to 84 goes down a little bit right it just it just seemed like I was trying to reconcile in my brain why that would be hi hi hi Richard yeah go ahead Carl I can take a stab at that it's just speculation obviously but you know once people get really old then sometimes they're getting their care through a specialist and sometimes the specialists can almost start to function like a primary care doc like an endocrinologist or a cardiologist and and so on that makes sense yeah thank you Carl yep and lastly um Vermont um we here at the Greenmont Care Board just uh formed a technical advisory group on um prescription drugs because we continue to see that as being a a large cost driver in rate increases and it looked like um you had a large discussion on rebates and I was wondering if our group should be reaching out to anybody that you talked to to try to get better insight on that so our discussion was basically we don't know what the rebates are so it wasn't that we could identify them at least that in in the group we were in um but you know I think others have have gone further and looked at those rebates specifically and they seem to be significant Carl do you want to add to that Carl are you sorry I don't have an immediate response to that I think there's one state that may be trying to collect rebate information I can't recall which state it is yeah if you come across anything shoot us an email okay I mean I don't remember I forget who it was but um I believe you know yesterday I mean it was uh there was some indication go ahead hi this is Lindsay um I thought yeah I don't want to speak yes in both um so I worked on this project for the primary care spend report for nesco and I'm also uh I've joined in with Christina and Robin in the pharmacy advisory group just in like a listening capacity and it's true that a couple of months ago the nesco group identified that potentially we were not seeing the full picture on pharmacy spend excuse me from claims and then um yeah like even just earlier this week um I sat in on a pharmacy group discussion and it was very evident that for Medicaid anyway in Vermont we're not getting the full picture on cost and so that you know it's it was a good thing that we didn't include pharmacy in this analysis right now um and I pharmacy data is of enormous interest to me so I'm I'm kind of excited to be both involved in the nesco effort and also getting to listen in on on what this group is is educating us about so so not to take us uh far off the field Lindsay but um I have had conversations in the past that dealt with um trying to um get the actual cost after the rebates and I believe there's a southern state that requires um a reporting that's fairly simple because apparently mcassan is the main um collector of all this data so just something that you may want to consider in your discussions at the um technical advisory group that there may be a way to get there um but again my knowledge is pretty limited so I'm not going to step in the quicksand here um with that I'll turn it over to other board members for questions for Richard or Carl. Kevin this is Michelle can I just make one point before we move on to other board members just a point of clarification sure so I just wanted to make sure and I neglected to mention this at the beginning but I think there's likely going to be a lot of focus on the commercial rate here and I wanted to point out that for the purposes of the model and the purposes of the act 17 report Medicare Advantage is considered commercial in the state of Vermont so when they're separated out in this report um that's not typically how we would show it and so that is part of the reason for the fairly large discrepancy between those two reports that you'll see I just wanted to kind of clarify that because I think it um caused some confusion at least at my initial read of the report so I just wanted to clarify that but on this report when we see commercial it's a standard definition across the six states correct correct so this is all standard my point was to say that for our reporting Medicare Advantage is considered commercial in the state of Vermont for the purposes of the all pair model so those two would be combined yeah I'm you know in some respects I almost and again I shouldn't say anything off the cuff but when you take a look at not including Medicare Advantage you're looking at the age demographics where hopefully some of the things would be addressed in primary care so they wouldn't get to full-blown chronic illnesses so I'm appreciative of this look without the Medicare Advantage but that's just me so with that other board members yeah I have a couple questions and just wanted to add on to some things that Kevin had talked about one thing that came to mind when I was looking at the commercial and even all these is when you look at the age brackets you did that across I believe all the states combined and you know do you have the age brackets by state individually because maybe there's some information there where it looked for commercial like the zero you know the really small children were much higher and then you know it tapered off to the to different it's in the middle and then it was got a little bit higher as you got older but you know that mix if we don't have the really young could skew some of that percentage so I I wondered whether we had the age brackets by state individually as well if you have that information um just looking at that I so I'm looking in the appendix uh we have it by payer broken out not by state is that correct Carl I believe that's right in the report we don't have not even out by uh I just wanted to do that maybe something you know that's driving the change and similarly on the opposite end of the spectrum on Medicaid where we're the highest for primary care um you know I wonder if out of state care for some of the other services might skew that number because you also said we don't have I believe out of state is not in there so so let's say someone went for some really high-end care out of state um and did their primary care at home would that sway that number so we did not exclude out of state there was discussion about excluding it uh someone from one of the states had concerns about if people were considering legislation you couldn't really impact out of state providers but for this study we never excluded out of state okay perfect I misinterpreted that um and then the last as you talked about you know for pmpm obviously the mix of what the practice has if they have older people versus younger you know that would skew that and I just wonder whether you know of any states if they have the capability to to do their pmpms at that level because I think that may be more of the concern right I get the concept that if I'm a practice and I have a lot of older population versus younger you know whether most states are going to that level if you're working with an ACO to distribute the funds so there are yes so in the development of the pmpm particularly capitated payments for practices there are risk adjustment methodologies that take into consideration gender age of you know the the members in the practice and it also risks to adjust for more comorbidities so uh so there are ways of doing that and I just thought you know when you look at these numbers it's pretty obvious that age is a pretty significant factor when you're looking at these practices and and this is another area where there's you know disagreement about the best way to approach this but um I guess there are certainly there are ways to create a risk adjusted pmpm for practice okay great thank you yep other board members yeah I I have one question um again going back to this 10.1 percent for um in Vermont um for the Medicaid program um could that be I mean this this could be a good thing but could that be driven by the more generous eligibility um availability here in Vermont and I'm sorry I went back and I looked at your your member count it was in table three I don't think it was up at all but you know if you look if you look at the Medicaid members in the study um in Vermont relative to the total members that were in the study it's 32.6 percent but you go to Rhode Island and um their Medicaid membership versus total membership is 24.6 percent and you go to New Hampshire and their membership um Medicaid membership to total membership is 15.1 percent so so it would seem logical that the Medicaid number would be higher relative to these other states and that possibly the commercial is lower because we have programs here that um uh like Dr. Dinosaur that um uh kind of step into the breach so yes Vermont is more generous in terms of Medicaid or has a higher Medicaid count but um that's not necessarily something to um you know compared to commercial because that that's a part of the market that they don't get um so I'm just wondering about that that um the the membership here was you know skewed pretty favorably toward Vermont in terms of of um achieving a Medicaid of the higher Medicaid number based on membership so oh Carl do you want to want to take a stab at that or do you want me to too well I guess I'll just reiterate this was a descriptive study um so we didn't get into trying evaluating causes of variation um I think everything you've said is probably astute and would be amongst the many factors to explore further um in terms of these variations um so yeah I think the one thing I would know uh that was Tom is that correct um you asked the question do you think yes yeah um I think I'm not sure the number of enrolled enrolled members in Medicaid I don't know if that would make a difference because we're looking at the percent of um so the 10.1 percent is saying that uh the primary care span relative to total Medicaid span was 10.1 percent um so it does indicate that they're getting more primary care services I think or that your Medicaid payment uh the allowed amounts are higher um so I think it certainly is worthy of looking deeper into that but I'm not sure it's entirely related to the number of members in in in the Medicaid enrollment um that would be my kind of sense of that but again I I think it you've raised the right questions I just don't I don't know that it's necessarily related to the membership well I I agree with you I mean it it isn't unknown and and the entire report has a lot of qualifications to it and it just seems to me almost a miracle that you got six states almost in the same boat at one point in time but you know that that did jump out to me as a significant difference among states um you know uh that New Hampshire in terms of the membership and and these are claims driven you know it's not eligibility from you know people that were enrolled in Medicaid but had no claims as I understand that these are these are people actually had claims and uh but Vermont you would expect Vermont to profile higher there because I think we have programs uh you know that that are are like Dr. Dinosaur that are um you know provide easier access to primary care for people in Medicaid um yeah I I mean I mean looking at it I would think you should be happy to see that number oh I am happy to see it that's it when I was finance commissioner we're under Dr. Dean we expanded Dr. Dinosaur significantly it was a Madeline Cunin program but um I you know I I'm I'm kind of looking at this is the result that we were hoping for yeah yeah okay other questions or comments from the board go ahead Robin this is Robin um I had a couple of questions um but before I ask them I would just also note on the Medicaid question that um Vermont has increased its Medicaid primary care reimbursement to Medicare levels which obviously will have an impact although who knows how that those two definitions compare your report definition to what the reimbursement increase was targeted at um I had questions about um some of the data so on the commercial slide on non-claims payments I was curious if the unknown category um reflected the commercial payments to community health teams or do we do we know what that is um yeah if you could I think it's if you could go to one more slide um or no it's one up one up like that nope it's the one that lists right the payments payments there you go yeah the 5.8 right um so what we did I mean so we got these payments and we had this template and the template was uh not the number you know the the payers told us how much money they spent but they didn't the way they categorized the payments was very inconsistent and so we went back to the actually the analysts in the states and said you know where do you think these payments went so if it was a p if it was a PCMH payment they were pretty well assured that those payments went to a primary care practice right Richard this is michelle I can I can take this one if you want me to okay I worked with the uh payers Robin on getting this data we use a very similar template through our total cost of care reporting to get this data from our payers so that's just kind of what we dealt with for the purposes of this report um so from our commercial payers specifically here for non-claims payments you would be looking at CHT and PCMH payments only because we can pretty firmly say those are primary care based payments um in terms of the unknown non-claims payments where you're seeing about six million dollars um that's very likely an underestimate so if you recall in the act 17 report we had the dollars that we could quantify but in addition we had sort of this outstanding appendix hey we know all these other dollars exist in the state of Vermont system but we don't act we can't say with certainty sort of how they are distributed so if you were to take all of the additional funds for example the 330 funds for clinics for the uninsured um if you were to add all of that that about six million number would be closer to like 25 or 30 million dollars um this was just what we could say you know whether this was you know risk-based payments or things like that we we kind of know the set dollar amount but in terms of if you were to really look at a full bucket of unknown non-claims that would be much larger. Thanks Michelle that's helpful um and in terms of the reporting recommendation um if I understood it correctly the reporting comes from the payers right so you're asking the payers to report the non-claims payments that they make up to providers or presumably to the ACO but the piece that that might miss would be any redistribution of dollars at the ACO level am I thinking about that right? Well at the ACO level yes or yes that's one way and then some of these payments are made in other states are made directly now remember these are commercial payments that were they're made to the hospitals or health systems and you know we don't there's no there isn't any uh request for the you know for the payer or the hospital or health system to say specifically where those monies went so yeah yeah so Robin for this um this wouldn't include for a concrete example this does not include value-based incentive fund dollars for example that flow through the ACO or our withhold of their quality programs we know they have a distribution model of the percentage of that that goes back to primary care that's not included here since the analysis for this report was 2018 specifically I believe in that value-based incentive fund has shifted throughout the year so just trying to you know something that we ultimately want to incorporate as represented here but not something we could do in time for this report. Sure and the the example I had been thinking of was the primary care capitation where there's additional dollars that flow to primary care who choose to move into that capitated approach but those dollars are coming out of like hospital dues for example. Yeah so I do not believe those are captured here but right yeah I mean I didn't expect them to I was just trying to think it through so that was helpful um the CPR program is also not included here I should add that to yeah for purposes of ACO yeah cool okay those were my uh two burning questions thank you. Super Jess. I just have two um one I think Richard well thank you very much for the presentation and Michelle and everybody Lindsey Carl who worked on this um Richard you mentioned at the end a comment about obviously there's no right number and the New England states are showing a six to eight percent roughly primary spend on primary care but you you reflected on other countries and I'm just wondering in your research for preparing for this presentation and this report can you just give us a ballpark of what for example Europe would spend I know that's often commented on the difference and certainly there's the proportion of primary care doctors in Europe is much higher relative to the US I'm just wondering as a benchmark or a ballpark what what does Europe look like. So I actually I looked that up yesterday I thought you had asked that. You know me too. It looks like it's in the 12 to 14 percent um in the European countries but again I'm not sure what's included in that definition you know so we don't know who the providers are what the services are etc so it would you'd have to dig a little deeper but it looks like it's in that ballpark around 80 percent. Great that's what I was thinking but I wasn't sure if that was just a you know and again it's true what's in the bucket is important. And my second quick question just is a lot of the a lot of this conversation has been around the percent of the primary care comparing the percent of primary care spend by payer across states and I'm just wondering if you have any conclusions or any thoughts on a comparison of the per member the PMPM by payer across states. So I saw like for example in one of the charts there you had the variation for example on definition two of Medicaid the low was 22 in some state and the high was 47 in another state. Commercial was 34 and 51 but in these in the presentation you didn't break it out by state but I'm wondering in your analysis so yeah can we learn from the variation in PMPM across states by payer. So for commercial the variation is from in definition one 23 to 31 dollars this is all payers all pay or no commercial I'm sorry commercial and then in definition two was 34 dollars to 51 dollars. Yeah so there's significant variation I want one state was a little higher and they were questioning the data for their state so excluding them I mean even then there's there's variation on Medicare Advantage from 32 to 36 in definition one from on Medicare fee for service from 25 to 32 and then and this will be in the appendix by the way it's not in right now but we're going to be adding that into the appendix. So you're going to add in by state so we'll be able to make room for one call PMPM by each payer. Yes that'll be really helpful to understand thank you. I can give you a spoiler we are in my last page of a book first so tell me. Nice one of my professors in college used to take all of her like extra credit questions from footnotes so I still to this day always read footnotes. So the we are for PMPM purposes would be so for commercial I would say we are actually like right in line with Rhode Island so when people often compare to Rhode Island on a percentage basis we look lower but when you look at it by a PMPM we're actually pretty close and the differences are as Richard's saying they are pretty significant as you go like from the bottom to the top but they're not all that different so it's just really interesting I agree just that was one of my favorite parts of the report so when I heard that it might be removed I thought for it so that's why it's in the appendix. Because I'm very curious to see it so when it's ready I would love to please share it with me. That'll be in the next next revision of the report so and give credit to Michelle for fighting for that one. Thank you. So she did get that in you know I think it was important to put that in also. Richard can I make one comment on the on the range of variation the so as part of this project we evaluated a lot of other studies that had previously been done and there's an appendix in the final report that shows the range of variation that some of these studies have shown and for the NESCO project the range of variation between the six states is either similar or much lower than the variability shown in some of these other studies for example Oregon did a study and the range of variation between the payers there is huge in terms of these kind of results so just wanted to point that out. Can I also just ask a question sorry just this question reminded me of another question I had related to the comparison between like definition one and definition two where you included a broader range. I know like in some states there will be a primary care office that will have like embedded medical technology like MRIs or x-rays or things like that so with those sorts of labs or those kinds of services that were in a primary care office potentially explain some of that variation between definition one and definition two I'm just curious about like what kinds of things are in definition two. Yeah I think anything that any of those providers build for would any service they build for would be in definition two so that yes those are the types of services that would probably be included and I think that's one of the suggestions is that we you know if we're going to continue to do these reports that the next one we would have a better sense of the impact which services had the greatest impact in increasing that percentage that are included in definition two. I just want to comment on the use of the word primary care office so one of the things we did state and we know is that in claims data there's no field to identify primary care setting so knowing that something was done in a primary care office cannot be done we use provider taxonomy codes to identify the particular types of primary care specialists for this project but we actually can't say for certain that this or that was done in a primary care office or setting for example if someone got a colonoscopy and for whatever reason the provider on that was identified in our taxonomy codes that might end up as a small part of definition two so. Got it. Thank you for that clarification that's helpful. Anything else from any board members? If not we're going to open it up for the public for a public comment. Does any member of the public wish to comment? Hearing none Richard Carl is fascinating report. We look forward to delving into those appendices a little bit further and thank you so much we know this has been a long project and we truly appreciate it. Thank you and I'm sorry you couldn't see me I put on a nice shirt and everything for you today. We'll just have to believe you. Thanks for the time we appreciate the opportunity to present it to you. No problem with that I'm going to recess the meeting until one o'clock this afternoon when we will resume with a panel discussion. Thank you everyone. Thank you.