 Good afternoon and welcome to the Green Mountain Care Board. My name is Kevin Mullin, Chair of the Board and I'm calling this meeting to, the first item on the agenda is the Executive Director's Report, Susan Barrett. Yes, good afternoon. I wanted to announce first off an agenda change for today's meeting. And right now, and I just had the page up but now I don't, but I think I can recall from memory. We're just switching essentially the two items that are on the agenda. We're gonna have the vital budget guidance go first and then the total cost of care discussion go second. And I wanted to announce that to the board and to the public. Any questions on that? And Mike will let me know if I have to do anything else. The other two announcements I have is, first our April board meeting schedule has been posted to our website. So that is under our meeting schedule and right under the header is a link to that April press release. Please keep an eye on that. There will be potentially some changes as we go along through the month, some additions and potential changes, but that is a good guide as to what we'll be doing for the next month. And then last, but certainly not least, we do have an ongoing public comment regarding the next potential next model with CMMI, CMS all payer model. That information is located on our website under ongoing special comment periods. There are slides that our team as well as the director of healthcare reform for the agency of human services presented to our general advisory committee and our primary care advisory committee. We're opening this up for the general public to comment at any time. But as a reminder, we are expecting comments back from the general advisory committee in writing by April 1st. And when we get those comments, we will share those with our partners at AHS and at the administration as they'll be leading the way on the potential next agreement. And that is all I have to announce. Thank you, Susan. The next item on the agenda are the minutes of Wednesday, March 24th. Is there a motion? So moved. Second. It's been moved and seconded to approve the minutes of Wednesday, March 24th without any additions, deletions or corrections. Is there any discussion? Hearing none, those in favor of the motion signify it by saying aye. Aye. Those opposed signify it by saying nay. Let the record show the minutes were approved unanimously. At this point in time in the meeting, I'm going to turn the meeting over to Sarah Kensler for a discussion on the vital budget guidance. Sarah. Thanks very much. I'm just going to share my screen. Can folks see the draft budget guidance document at this point? Yes. Excellent. All right. Thank you. So for the record this is Sarah Kensler, Director of Strategy and Operations at the Board. I'm here today to present draft annual budget guidance for the Board's review of Vermont Information Technology Leaders Budget or VITAL. The goals of the draft guidance... There's an echo that I'm hearing. I don't know if others are hearing that as well. I think it is gone now. All right. So the goals of the draft guidance are to provide clarity to the Board and to VITAL about the regulatory timeline at the Board's vital budget review and the contents of the budget packet as well as clarity around monitoring activities including quarterly updates and a mid-year budget update. And I should have started this by saying the Board has been reviewing by VITAL's budget only for a few years now since I think 2016. And so it's it's been historically a slightly less structured review than some of our other than some of our other regulatory processes. And in seeking to introduce some guidance into the space I think it will it'll add clarity on a variety of levels. So in addition to clarity around the kind of budget review timeline and the contents of the budget packet we'd like to introduce some more clarity around monitoring activities including quarterly updates and a mid-year budget update. These have been included in the Board's decisions for the past few years. But detailing the kind of consistent elements in guidance ensures a more consistent schedule on contents. In addition it will support collaboration between the Board staff DIVA and VITAL in the budget development stage so that we can anticipate potential budget changes in that mid-year update and to better document the process contents and timing of the mid-year submission. As a reminder for board members VITAL's fiscal year begins on July 1st when their contract here with DIVA and the bulk of their revenue begins on January 1st. This Disconnect has meant that over the past couple of years we've had a need to do budget adjustments or mid-year forecasts once that DIVA contract was signed. And our hope is that by putting some some some more structure around the mid-year update and around kind of how we deal with that Disconnect will help ease that process. In addition finally it will clarify the Board's principles for review which haven't been updated since we took on a vital budget review in 2016. So before we jump in I just want to note that this guidance is meant to be non-year specific so it won't need to be re-reviewed and approved by the Board each year unless there's something that needs to change. To that end there are some pieces that are left to staff to specify or left to the Board's budget order to specify to allow us for for some flexibility or tier if something's kind of not working as it should. All right so moving on to the second page we're in the introduction now here we include the statutory language as well as the principles for the budget review that the Board uses in making its decision. These are adapted very very lightly from the existing criteria which I'll just toggle over to from a second for one second. These are from the 2019 staff presentation. And they are almost identical re-organized a tiny bit. I just want to note that what we did do is remove review of vital score activities from these principles which had been removed from our statute in Act 187 of 2018. So next we'll move on to Part A on page 3 and this is really the meat of the actual submission but you'll see that that theme kind of continues of you know we're not making too many huge changes here. It's more that we're kind of codifying our previous practice. So here we get into the meat of the actual submission and Part A covers the budget submission itself. The vast majority in line with what Vital has submitted in past years through kind of the informal guidance process. Section one is the budget narrative and there are a couple of changes that I'm proposing here. The first is in the key work stream section and then there are a few changes to again try to to get at that better estimate of the diva contract at the start of the budget year. So in key work streams I just want to highlight that number two here requires submission of two tables or two submissions with with the format to be specified by staff. The first is new but it will help us get a better link between the vital budget and the HIT plan by using the same framework that the HIT plan uses to look at the technical architecture and kind of like the different components of the health information exchange which which is the ONC's conceptual IT services model also known as the STAC diagram. That second table digs more deeply into a few key areas and like spending with metrics and that's something that was submitted to us last year and something that board members and staff found helpful. So we would like to keep that for a long term. And I've included draft templates for both of these tables at the end of this document to kind of give us an idea of what we're hoping that vital will submit and this is probably the format that I would as a staff specify this year and then we could see if it if it wasn't quite working we could make some tweaks we needed to but I've included draft templates for both of those tables at the end of the draft guidance. Now scrolling us back up. The other thing that I want to highlight here is under proposed FY budget bullet C here. The the first and third sub-bullets here are both aimed at getting us to a place where there's less variance between the approved budget and the final revenue from the diva contract for the coming calendar year. Noting that the past few years have been exceptional due to you know anticipated changes in federal HIT funding and due to COVID. We're also asking about other anticipated revenue here which will tell us a little bit more about what vital extracts from other contracts that might be signed mid-fiscal year. But we're hoping that this will get us to a place where we don't need that mid-year budget update as much because the that what we've been told to anticipate in the budget and what is what comes to to be in the contract are are very similar or kind of within a within a certain variance. Section 2 is the actual budget submission and nothing there nothing significant has changed there. Same goes for sections 3 4 and 5. I do want to note that section 4 pertains only to vital's revenue not to its contract with its vendors which we do not receive. So that is all that that's the budget submission. Next I'm going to move on to part B which is that work the reporting requirements. This lays out some kind of more detail than we've previously included in in the budget order conditions so it'll give us a little bit more detail and clarity before the start of the budget year about what we're what we're anticipating and we'll give vital more clarity there as well. The changes here that I want to highlight for board members and the public are that for the past few years we've required quarterly presentations to the board from vital that have included both report outs on specific projects as well as kind of a set of quarterly metrics that are the same over time that give us kind of a look into vital's performance on various things including you know interfaces including how many alerts have been sent over their systems etc etc. Rather than requiring vital to come in four times a year which has been hard to achieve practically just due to our various schedules this draft guidance proposes to require presentations twice a year with brief written submissions each quarter. These will include this that same data that the board's been receiving quarterly in the past plus highlights from key projects that are named in the budget order. Again that's a spot where we left some flexibility to change things annually since there will likely be you know new and different projects that the board would like updates on each year. My understanding from vital is that these quarterly updates are fairly low burden and that this would not be a challenge for them to kind of switch to a written update versus an in-person update. My guess is that those in-person updates twice a year would likely naturally fall to be around vital's budget presentation which happens in May or June and to the mid-year budget update which happens in in you know midwinter. Speaking of that mid-year budget update the mid-year budget updates are a relatively new phenomenon driven by that disconnect in the timing between the fiscal year and the terms of vital's contract contract with DIVA and this has been the case since 2019 only. So that said the guidance is working to push us toward more reliable estimates which would decrease the difference between what is anticipated for the contract in the budget and the actual terms of the contract. So our so what I've laid out here in the draft guidance is an option with kind of two paths if if the budget exceeds a certain variance will get a more significant mid-year forecast. If the variance does not exceed a certain threshold then then we'll get you know a year-to-date financials. And then again if requested we can always you know require vital to present that mid-year update to the board at a public meeting. So that is the the complete guidance right there. Happy to talk about questions. Questions from the board. Are there any questions from the board. I don't have questions but I did just want to comment on a couple of things. I do think it makes sense to talk about you know really seeing them you know twice a year versus four times a year. I mean you know we really just have a review of their budgets and when we look at some of the other processes we have like the hospital budgets we don't even see the hospitals in a public format you know typically we don't see them four times a year. So it seems and I know scheduling and things like that also you know play a role. So I think that makes sense. And I also think you know looking at a variance I know there's a disconnect between when they get their contract signed and you know 500,000 or 5 percent I think is is more than reasonable you know even if we'd gone a little higher I think that would be okay too but let's see how this goes you know because we all know you know a budget we're going to have variances to budget and so 5 percent isn't even that much of a swing. So so I think it's good to put some parameters on there and down the road maybe even there's room to go more if we wanted to. But you know great great way to kind of rein this all in and kind of formalize the process more. So thanks. Other questions from the board. I don't have a question but I do agree with Maureen's comments and Sarah I think you did a great job pulling this together. Sarah what it what would be the next steps. The next step is public comment period. This will get posted this afternoon for public comment on the public comment page of our website and then we can we can hold a you know a potential vote if the board is ready on the 14th. Okay. Any other questions from the board. I don't have a question either. I've read this and reviewed it the other day with Sarah and I think it's definitely moving in the right direction in terms of making the process more integrated from a contract point of view and a fiscal year point of view. And also I think the three to five project streams presentations give the viewer kind of a more visceral understanding of what some of this technological lingo might be leading to. So I'm happy with it. I think Sarah's done a great job as well as the folks at Vital that she's working with. From my point of view it's good to go. Any other comments from the board. If not we'll open it up for public comment. Does any member of the public wish to comment. Seeing and hearing none. Thank you Sarah. As usual a concise presentation and again the public comment will be open up and we'll come back to this on the 14th. Thank you all very much. So with that we're going to move on to a discussion on the all payer ACO model update on quality and total cost of care. And for that I'm going to turn the meeting over to Michelle DeGree and Lindsey Kil. Whenever the two of you are ready. Unmute yourself. Good afternoon. I am Michelle DeGree. I am joined by Lindsey Kil. I'm just getting our slides ready here for presentation. I will share my screen just confirming everyone can see that. So Lindsey and I are here today to talk to you about the 2019 final results for total cost of care and quality. We'll do a brief update on or an overview on scale. But the main focus of this is to again just do the final year end for 2019. I know it's hard when we're already in 2021. So for the purposes of this presentation we're talking about performance year two of the agreement and which again we're in PY4. So I know it gets confusing but trying to think back to 2019 and with that I'm going to turn it over to Lindsey. Thank you Michelle. Hi everyone. Good afternoon. My name is Lindsey Kil. I work on the analytics team and today I'm going to talk with to everyone about the financial updates and we're actually going to start by level setting with revisiting the discussion on scale. A few of these slides including slide three in front of you now are repeats from what we went over in December for that presentation. But I think it's helpful to discuss scale before we get into numbers. So when we talk about scale what we're talking about is the eligible population to be measured within the all-payer model agreement. And specifically in our reporting on slide three here what we're showing is the actual proportion of members aligned with the ACO at the point in time that we're discussing performance year two 2019. So the way to read this is that in 2019 the proportion of the population enrolled with the ACO as as the subset of the total cost of care is 47 percent. The target was 75 percent but 47 percent is the blended total across all payers. Slide 4 please. Thank you. So on slide 4 what I've done is I've broken out that blended scale number of 47 percent into the payers that are participating. In green we have Medicare. In blue we have Medicaid. In a darker green we're showing commercial fully insured and then separately in a deep blue I'm showing commercial other and under other commercial is commercial self-funded and Medicare Advantage. And I did that because actually as we show the proportion of scale for people for those groups who are aligned with the ACO Medicare Advantage is not aligned with the ACO at this time and so it was just it was a highlight on zero and we thought that that was a little hard to read so we we grouped them. But it's important to note here that there's no Medicare Advantage alignment with the ACO in this model year. We can see here that there's growth from in Medicaid and Medicare and commercial both fully insured and other there's some growth but not a ton in between 2018 and 2019. And so we wanted to demonstrate we wanted to talk about that first to really hearken back to what proportion of the population we are talking about in these total cost of care results. Slide five. Great. So just a couple more notes on scale. You have another report coming out in June 2021 that will include final numbers for 2020 and the projected 2021. Projected 2022 will be available when we've received one CARES 2022 budget based on the contract negotiations at that point in time so we don't have those right now. Additional changes to keep in mind in the background of all of this because the total cost of CARES is really everyone in V CARES and then as a subset of that it's those aligned with the ACO. So kind of balancing these two populations in our mind but the Vermont State Employees Association or VSEA was added to the scale qualifying population recently and that's included in the proposed 2021 budget. So that's going to be a change to our scale numbers. And then also going back to Medicare Advantage over time more Vermonters are opting for Medicare Advantage. Since Medicare Advantage is considered a commercial payer in this model we're really seeing that potential scale taken from Medicare growth and moved into commercial. And since they are not currently aligned with the ACO the state is discussing ways to include them in the future in the model. But as Michelle said where we are in 2019 with these results MA is is under would show up under commercial non-ACO. Slide 6 please. Or slide 7. So now we're going to get into financial results. Again we're in performance year 2 2019 and as of this year 2019 we have three years of Medicaid data in the model and we have two years for Medicare and commercial participation in the model. And then on slide 8. Thank you. Here we're comparing expenditures in millions really just to see where the all payer model total cost of care fits in the overall discussion of Vermont medical spend on behalf of Vermonters. The slide should be familiar to us from the December presentation but we thought it was a good one. So we re-included it. So for 2019 from our expenditure analysis estimate we we believe that we'll land somewhere at or above 6.4 roughly 6.4 billion for total Vermont resident spend. A subset of that approximately 46 percent is what is captured in the all payer model total cost of care in terms of total spend on behalf of Vermont residents. And then a subset of that even and 14 percent of the total spend is the 881 million captured in one care Vermont's own total cost of care budget or not budget excuse me 2019 in final numbers that they showed in their 2021 budget. Got it. And I have citations underneath for all of those. On slide 9 please. Here on slide 9 we're just diving a little bit more into since the all payer model total cost of care only captures that 46 percent well what is that other 54 percent. What what are those services and those people that we're talking about who are not included. This is really a result of trying to align all of the different payer plans so making Medicaid and commercial align more with what it is that Medicare covers and so we are so in that 54 percent of expenses not included in the all payer model we're seeing retail pharmacy dental expenses behavioral health and substance abuse expenses. And then there's some of these different populations like Medicare Advantage federal employee plans workman's comp etc. Slide 10. Thank you. Here we're showing again trying to combine this perspective on scale with the perspective of the proportion of spend that we're seeing in the total cost of care. There's that total nearly three billion figure and we can see that of that total Medicare comes in the highest they have 44 percent of the expenditures in the total cost of care despite representing 27 percent in terms of member months. Medicaid comes in the lowest for total cost of care expenditure proportion but is around Medicare's proportion of member months. And commercial is fairly even. Commercial is 42 percent of the total cost of care and 45 percent of the member months. I really like this graphics I think it shows how varied it is. So slide 11 we get to the answer of the best question how did we do in 2019. Between 2017 and 2019 what did the total cost of care how how much was that total cost of care change on behalf of Vermont residents. And that the answer is 4.6 percent. And it's important to note that while we monitor year-over-year change Vermont's performance is really assessed from 2017 to date with the focus on the outcome at the end of the performance period which is performance year 5 or 2022. And slide 12. Thank you. Here's a little bit more detail about the breakouts by payer that contribute to that total 4.6 compounded annualized growth. And I've also included from the National Health Expenditures numbers the growth between 2017 and 2018 which is growth performance year 0 to performance year 1 and then 2018 and 2019 so growth between performance year 1 and performance year 2. We had those national estimates from their data that was released not too long ago so we're showing 4.7 and 4.5. Those are just benchmarks they include much more than claims so but we thought it was good to show that. And the all-payer model specifically the 2019 file final numbers is $549 per member per month with the 5.2 percent growth from last year. And by payer when when you look across the different payer groups we can see that there's growth concentrated in commercial. I do just want to give a disclaimer. I'm going to talk a little bit about more about commercial numbers on the next slide but it's important when we think about scale and we think about how our scale both in and outside of the ACO is changing over time that until scale is stable it's tough to compare these numbers between year over year. But we do we did just want to include all of them on this slide because these are the numbers that go into that calculation of the compounded annual growth which we're all looking at. Slide 13 please. Thank you. Slide 13 is yet more detail into what was included on slide 12. This breaks out the all payer and per payer total cost of care per member per month based on ACO enrollment versus non-ACO enrollment. Before I go into a little bit more detail on those results I do want to add that there's currently work that we're undergoing with NPR on looking at cost drivers in and out of the ACO. So really to provide more detail into all of this what we're seeing but what we can say on this slide. I spoke before about commercial that 7.5 percent between 2018 and 2019. This is really the highest area of growth and is driving that 5.2 percent. What's notable is that the ACO commercial group where there was 10.6 percent of growth is actually it's a fairly small population it's only about 30,000 people in Vermont. The largest contributor actually is the non-ACO commercial group. This is 6.9 percent growth year over year or 3.9 percent compounded annual growth and that group is more like 250,000 people. And within that group is Medicare Advantage who as we said before is at the time not participating in the ACO and so they have quite a lot of the spend growth attributed to them in their plans. So and again more detail coming on all of that comparing in and out of the ACO through this work that is currently in progress. So slide 14 please. Thank you. So after looking at the finances we thought it would be a good idea to take a step back and look at a very high level where the state's influence is and over what groups in the total cost of care. And so what I've done here is grouped all of the enrollment groups that you saw from slide 12 and 13 into whether there is some state regulatory control versus no state regulatory control. And when I grouped those that way we have under some state regulatory control we have Medicaid ACO and non ACO aligned Medicare ACO aligned and commercial fully insured who are all under some state regulatory control. Where there's no regulatory control is Medicare non ACO aligned Medicare Advantage and the majority of commercial self funded. And so on slide 15 I just want to show kind of an interesting perspective if we take from the total cost of care annual final annual numbers if we sum the total dollars across all of these groups for which there's some regulatory control and we sum all of their member months so the proportion of market penetration we can actually see that the ACO within the all payer model has allowed us to bring more control more dollars under under some regulatory control and more insurance market penetration under some regulatory control which I thought was a really interesting perspective. And so that's what we're seeing here. And slide 16. Great. Thank you. So these are just the key takeaways. Again majority of performance year one to performance year two growth is from commercial. The emphasis is really on the Medicare Advantage population. They were not participating in the ACO during this period 2019 so there's less ability to control these costs. There was some growth we saw in the commercial fully insured population. That was that 10.6 percent between 2018 and 2019. That is really from the Blue Cross through Shield risk pool change and also their rates increased in that time. So that's really what we're seeing. There is growth of course in the other payers and a lot of that is reflected through the change in demographics as people in Vermont age into Medicare and Medicare Advantage populations. And as I mentioned before more people electing for Medicare Advantage coverage instead of traditional Medicare. But overall the model has brought more of Vermont's healthcare system wide spend back into state regulatory control which is can be a good thing depending on you know what we think about how we might affect some of those costs. And then slide 17 looking ahead we are anticipating more detail on utilization and costs for ACO aligned versus non-ACO aligned members. And that's current work and as soon as we have those results we're excited to share them. We are expecting utilization to be lower in 2020 due to the COVID-19 pandemic. And so for this reason although the 4.6 percent is higher than that upper bound 4.3 percent we're not expecting a triggering event. And lastly just a reminder that on April 14th AHS will be presenting to the board on the all-pair model improvement plan for considerations for next steps. And that concludes my share of the slides. I'm going to hand it off to Michelle. Thank you. Thanks Lindsay. All right. So now we're going to jump into the 2019 Quality and Population Health Outcome portion. Before I dive into the good stuff I just want to talk about a couple of considerations that we need to keep in mind when reviewing these results and some of these are semi-redundant to what you heard from Lindsay. But so as with the 2018 Quality Report all of the data presented here are based on the mutual understanding of the technical changes amendment that was in progress at the beginning of 2020. As you'll recall we were going through a process with CMMI to make some technical changes to the agreement that was put on pause due to the public health emergency. So this report is also produced kind of based on that mutual understanding and agreements that we had come to before that process was halted. I want to talk about a couple of things. So public health emergency first due to the ongoing COVID-19 pandemic this report does not provide an update on all measures we're missing too. For those two measures that are missing they require some level of the health department's involvement and analysis and since the health department has been sort of on the front lines of the pandemic and switching their priorities to focus on the response. There's a couple measures missing and once we're able to get that from them we will update the report and update the board on those results. But for now they just remain not included here. Lindsay touched on scale a little bit so I want to talk about it in in terms of its impact on the quality results. So while model performance on quality measures obviously about most important it's also important to note the underlying denominator changes in many measures specific to the ACO aligned population. So when more Vermonters enter scale target qualifying programs it's going to introduce volatility in our ability to compare data from year to year. As we know once attribute attribution sort of starts to plateau it'll be easier to draw conclusions on aligned beneficiary health and quality over time. These sort of increases in scale coupled with the fact that trending is not super advised. With only two years of data I just want to caution folks in their interpretation of results at this kind of early juncture. And as you can see on the slide there was a 46 percent growth in scale in both the all-pair and medicare population so the denominator for these measures went up between 2018 and 2019 by 46 percent. And risk so risk scores as we learned from our peridifferential reporting there are a way to compare populations based on health care utilization and predict future utilization patterns. And from that peridifferential report we know that ACO aligned members have about a 2 percent higher risk overall than the remaining population in B-stores. So with that let's dive in. A couple of level-setting things as we go through these slides the the arrows are meant to be helpful but I have learned in many conversations tend to cause confusion so I'll tell you what I meant by them and if you decide do you want me to take them out I will. The direction of the arrow is the change flashier whether it went up or down and the color is supposed to help us indicate kind of the the movement towards our performance year five goal. So if caution should be exercised or if there's you know a super big area of concern here. So talking about population level health outcomes targets as you can see from this slide there's one that we've indicated as sort of a cause for concern and that is the percent of adults with a personal care doctor or provider. The rate has decreased in the base year which is that 87 percent in 2017 and it's now at 86 percent which has remained the same across 2018 and 2019. The goal for PY5 is to get us to 89 percent. So obviously a decrease is not making that any easier. I think you know this is just an area that we want to look out for and continue to monitor. I know while I wasn't here at the time of the negotiations the rate itself for the target was based on the highest performing state at the time which was Massachusetts and so it's just something we're going to continue to monitor based on these behavioral risk factors surveillance system results. So these come from the Brefist Survey which is administered through VDH and CDC. We'll continue to monitor sort of the highest performing states to see if that level might also be dropping. But I just wanted to point that out. Another piece that I'd like to point out is so the first measure listed here the deaths related to drug overdose. Well I was able to receive the 2019 rate for the measure as it is specified in the agreement. The health department actually is moving away from reporting in this manner so that all drug overdose deaths and is moving more specifically to an opioid related measure. And so I have put in the written text of the report and also we'll be working with CMMI to see if the updated measure that they're now reporting is a viable substitute. Just recognizing that if it's something they're regularly reporting and updating we don't want to have duplicate work or additional work if there's a measure that we can use in its place. So just to flag that as well that that could potentially change in the future but is something that they would be able to provide trend data on so it's not like we would lose ground. With that I will go to healthcare delivery system quality target. So the gray shaded cells here is an example of one of the measures that are missing from our data. So here I think it's important to sort of note the promising results. A lot of the measures on this page are among ACO aligned beneficiaries. And the the one area of concern that we've noted there is the 30 day follow-up after discharge from the emergency department for alcohol or other drug dependents. Try saying that one 10 times fast. So the denominator here the eligible population for this measure increased by 58 percent over 2018. So when you look at the 2018 report and you see the denominator there it's much smaller. And so just thinking through that as we as we start to interpret these results again sort of giving some caution to that with the large increase in scale between performance years one and two. This is a good example of that. I think there's been some really great improvement in other measures for the ACO aligned population and I'm hopeful that we can take some learnings from there and apply it to this the alcohol and other drug dependents follow-up. There's also some confusion on this page around the diabetes measures here. As you can see the 2018 rate and the 2019 rate are drastically different though they fall within the same percentile range and that is due to a decision at the federal level. So the 2018 number that you see is actually used to be a composite measure. It was this measure coupled with a diabetic eye exam. The federal level that was disaggregated starting in 2019 so moving forward we will have simply the HB A1C hemoglobin A1C poor control measure but that will not change the 2018 rate at this time. And again because we're working on falling within a National Medicare Benchmark range this kind of still still works and we are within that range at this time. Third and final the process milestones again here we see some grade cells so the remote prescription monitoring system data are currently unavailable. With that though you'll see in the written report that the health department has the grammar reporting on morphine milligram equivalent per 100 residents. And again I'm working with the MMI to see if this measure could be an accessible substitute over time given that it is now in their sort of recurring measures that they're producing and publicly reporting and do have historical data on that measure as well. So potentially a change here still to be determined but anything that we can sort of avoid asking too much of our our health department partners especially as the pandemic continues I think is really important. And just to point out here a really positive trend that we're seeing as a Medicare adolescent well-cared Medicaid adolescent well-cared excuse me. We're seeing a steady increase in that current trajectory that we're seeing is setting a selfless and promising growth by performing 25. Given the public health emergency though I will point out that GMCB along with everyone in the state and across the nation are going to be monitoring rulemaking and any measure changes and that this kind of goes for all the measures that we're talking about here but this one specifically to account for any telehealth utilization and changes that may come to national measure sets based on the public health emergency and you know should there be any changes to future versions of this report. This is a HEDIS measure so if HEDIS were to update for their 2020 plan year we would want to make sure to reflect that as well. And the question then becomes you know would it be something that you would have to back date to 2018 and 2019 results or would it simply just be a change in methodology that began in 2020. So again all of that to be determined all that to say. We are currently on track to meet five out of six of our population level health outcomes target seven out of eight available health care delivery system quality targets again that one being unavailable and five out of the six process milestones again with one of those unavailable. I will say just given our current state I'm pretty pleased with our 2019 results and of course have some caution as to how may we might be able to interpret results for the life of the agreement as we move forward just recognizing what the pandemic has done across the board for data collection and interpretation. So as I've stated several times now we will continue to monitor and consult with our federal and state partners to ensure accurate data reporting and to reflect any measure changes at any level. So looking ahead Lindsay talked about a couple of these earlier but we're looking at a comparative analysis for our across performance years one and two of our continuously enrolled ACO beneficiaries. So those who are enrolled for at least 11 months in their peer group and were part of the ACO. So looking at their sort of trying to track those folks over time as they move through the years of the agreement and as Lindsay stated we're also working to better understand the model's impact on access and utilization services and you know more specifically looking at inpatient outpatient and primary care cost drivers. Just to round it out upcoming all-pair model reporting this year so the 2019 annual TCOC report will be released as soon as we can get it. We have been working on this one quite nonstop for the past few weeks now we got a couple of new data points that needed to be incorporated and they did make it into this presentation but they need to be reflected in the report as well. And so just making sure that we have all of the most accurate information in there before that published publicly. Then following that as Lindsay stated we've got our scale targets and alignment report for 2020 and that will be coming out in June. We have another annual peer differential report which will be a 2020 so it'll assess the peer differential between 2019 and 2020. And then at the end of this year in concert with AHS is the proposal for the subsequent agreement. So as Lindsay said they're coming in to present on the all-pair model improvement plan in a couple of weeks and I would imagine shortly after that we would start to hear a little more about the planning process for that proposal. That's all I have for you. Thank you Michelle. I'll kick off the first question Michelle. You know obviously this data is a point in time and that point in time is 2019. Do you have concerns about the fact that the health department has seen an uptick in the number of ODs during the pandemic? Yeah that's an unfortunate but really good question. So we've heard sort of a lot about that. There was a lot of conversation about it sort of last summer when it you know when we had the first sort of it's not really a lull but lull in the pandemic and started really reviewing some of those data details. Unfortunately I think a lot of it is due to fear of accessing emergency services. So I think continuing to work with the health department and their tracking and monitoring and seeing what else can be done. But it is absolutely a concern in terms of model performance but as a human you know just in terms of overall health and well-being of Vermonters. Okay I'll open it up to the board for questions or comments. The question on Lindsay I just wanted to make sure that I understood the way that you talked about the slide. I'm sorry I didn't note the number that has the expenditure analysis the total cost of care. There you go. The next nine I think it is perfect. So when you were talking about the types of expenses that were not included the the box that's under 8 p.m. total cost of care some of those things are in the total cost of care but they're not in the one care total right. So for example the total cost of care is based on physician and hospital services with some exclusions for groups that aren't included in v-cures. But for example Medicare Advantage is included in the total cost of care but it is not included in the one care box. That's correct. Okay. All right I just wanted to make sure I understood that because it was a little confusing to me. And so I just want to clear that up. Thank you. I wanted to also just ask about slide 14. So this is probably lawyer picky so forgive me. But when when you use the term regulatory you are using that term to be inclusive of contractual agreements. So for example Medicaid doesn't regulate the ACO but they do have a contract through which they influence the ACO program. Yeah I think we were when we came up with this high-level look we were really thinking about the areas in which and there's any entity it at the state that has some regulatory control over these payers. So Medicaid is that there is some state-level control. That's the policy right. OK yeah that's what I the way I thought you were using that term but it's a little bit broader than how I would use it as a lawyer. So I just wanted to clarify that. I think then you could also include this wouldn't apply obviously to 2019 but in the future there is some state control over for example state employees and education employees. Yeah we were thinking that I almost put like an asterisk on this slide for the state employees and for the teachers union for that reason. Yeah in terms of the self-funded groups. But that is I think for this high-level perspective we were just hoping to kind of yeah keep keep it high level for now. But if this is an area of inquiry and of categorization that you all are interested in then I think we could do more detail in the future. Well yeah I know I thought it was an interesting look and I appreciated slide 15 as well kind of illustrating that point. So thank you for that. And then can we go to slide 16. So one piece that I just wanted to circle back to just to make sure it's fully clear is so what happened in this year is that Blue Cross Blue Shield lost market share to MVP. MVP was not participating in the ACO. So that basically meant that Blue Cross you had one carrier in one carrier out and as a result of that market shift Blue Cross is as you noted risk pool changed significantly. So but I think the other piece of it that was that I just wanted to point out is that MVP wasn't participating at that point although now they are. So just to round out that story. Maybe we can if you'd like we could update the slides and I could put that either as an asterisk or maybe in parentheses there like which one is in and which one is out at that point. So do you think that's a good point. Thank you. And that those are really the areas that I just wanted to clarify and make sure I was thinking about it holistically. So and thank you very much to both of you. Okay. Other members of the board. Well maybe I'll just jump in. Go ahead Maureen. Now you go ahead. I'm just going to build a little bit on Robin's last point about Blue Cross Blue Shield being in in that year MVP being out in that year and the risk underlying risk of those populations being quite different will definitely contribute to our understanding of the commercial the ACO and the non ACO spend within the commercial population for that year. And I'm sure this is something that Mathematica is doing in their report. But I just wanted to emphasize that we need to understand the risk pools there and the demographics and all of that of the different populations. And I'm looking forward to that report. I'm actually one of my questions was when is that report or that analysis coming out. It will be a little while. The ad hoc request is just approved through so Mathematica also has a subcontractor so it just made it through that approval process a couple of weeks ago. So it'll it'll take some time. Yeah. I guess I just wanted to that summer fall winter. That's summer. Yeah. I would not. I don't know. I'll take myself here for saying that but I would imagine that yes it would be available in the summer. That's pending you know what the board wants to dig into a little deeper once we get our initial run of data. Got it. My second question Michelle was about the you know given the importance of the primary care providers having access to a primary care provider and all the emphasis that we're trying to put on primary prevention and all of that you know that you know your your red arrow there of you know 86 percent with a target of 89 percent. I'm just wondering what can we is this is this percentage coming from the Vermont health insurance survey. What is the underlying data and what can we unpack about is it geography. Can we learn anything about geography where people have access where they don't. Is there anything about insurance status type of insurance status age. How do we unpack that access question there. Yeah. So this data comes from the behavioral risk factor surveillance system which again is run through BDH and CDC. These data that I've presented today for 2019 are publicly available because I was given permission to produce them and report them out. But BDH in its current state hasn't had time to produce their annual report that they typically do along with the breathless results. And within that you would see things like you know a lot of times for for measures like this it's male versus female. It's some of sometimes it's insurance status included but it does kind of vary from year to year. I think once we're able to see sort of their dig at the data I just get like a very simple Excel file with the results that I need. But they also have the ability to dig into you know are we seeing variation by health service area are we seeing variation in other ways. And so I think we'll kind of have to wait until until they're able to produce that report to get some more detail on that. But while it's not while it's not trending in the direction that we would want it to compared to other states I still think we have incredibly high access. So something to also keep in mind and like I said I'll continue to keep a pulse on where the highest performing state is and at the time that 89 percent was Massachusetts. No that's great. I'm just thinking if we had a better understanding if we could do a deeper dive we might be able to identify solutions right. How do we start to you know reach the folks that are not being reached right now. So thank you. Yeah I think I think that's some of the analysis that we'll do again it's a different data set because we'll be using sort of claims based data but when we start to look into utilization patterns and in and out of the ACO type information we'll be using again different data set but can sort of do some digging into that as well once we receive some of those initial analyses for Mathematica. Great thanks. Okay other board members. I have a couple of questions. If you could go to slide 13. There we are. So down here in the lower left hand corner you see the the first asterisk that says excludes permissible price increases relating to Medicaid. And I'm just wondering if we have a dollar value for those or some metric to know what they are in terms of scale for 17 18 and 19. You know how much you know I mean I understand the principle in the all-paramodal that makes sense to me but I'm just wondering what are the numbers. Is the amount that is being excluded growing or is it flatlined or is it diminishing. So I can look up the exact dollar amount after this call and send that to you. I can say that in the in 2019 it was 4.6 percent was the adjustment. And in 2018 it was 2.2. Yeah. Okay so that's helpful. And one more kind of query. I I sometimes don't know how to look at these quality metrics in these early years because so much hasn't happened that people hope will happen with the all-paramodal and the ACO. For example you know when it comes to pre-diabetes Vermont's benchmark plan doesn't even offer that benefit and my hope would be that as the benchmark plan gets revisited that the alignment between what the blueprint provides which is the CDC program and what is the benefits that are allowed by MVP and Blue Cross Blue Shield will be better aligned and clearly that's a big part of the metric having to do with diabetes in terms of the quality metrics. I would also say maybe the same thing for FITS prospective payments you know in that in 18 and 19 you know they were single digits and we've crept up slowly to about 14 to 15 percent in 2020 and 2021 but still aren't at a level is my understanding of any kind of critical mass that we really might be seeing the benefits in terms of improved quality through a fixed prospective payments. I mean I think one example that counters that is the is the Southern Vermont Medical Center which seems to they have a 22 percent FPP rate and they seem to be using that freedom to restructure their transitional care. So I guess is it would you agree that you know that to that we shouldn't be taking these metrics these 2018-2019 metric too seriously that there should be big asterisks around them because they are still early in the game statistics and just a lot of the context and environment that we're trying to create you know to improve health care quality just hasn't happened yet. Yeah so I a couple of things. First you know one of the main points that I made was around scale increasing between the two years. So specifically when we're talking about that ACO population having it nearly double makes it really hard to compare things year over year. That's part of the reason why in some of our other tables where available we give the numerator and denominators that you could look at them in the 2018 report and see that change and that growth would absolutely caution people making comparisons from year to year. You know the two years is not a trend. There's a lot of volatility when we're increasing scale at this rate and in addition to that you know once we have a third year which is where I'd feel a little more comfortable our third year is 2020. Like that's not helpful and we don't really know what that's going to look like yet. So I think there's also sort of this uncertainty of truthfully the ability to trend at all right and through the life of the agreement depending on what we see for 2020 and what our results start to look like. It's a fear that I have you know we have starting in year three we have to meet a certain threshold of achievement towards a goal for performance years one and two for quality metrics specifically. We just have to be making progress and we've shown that we've done that in in the two years that we have data for. But with 2020 being year three and needing to meet that threshold I have some concerns about what we might be just given sort of our anecdotal understanding of reduced utilization in general and without that being coupled with potential changes and how some of these measures are actually calculated at a federal or a state level. So are they going to start including or broadening their sort of back to include things like telehealth or telemedicine visits whether it's phone only or not. How are those types of changes going to be made and so until we see that play out I honestly don't have a good answer for you. I think it's it's hard. It's this is you know only two years so take it with a grain of salt. I think it's it's very promising but at the same time we don't know what 2020 is going to look like or 2021. Thank you. That wasn't an answer. OK other board comments or questions. I said one comment I mean there have been a lot of the questions I was looking at have already been addressed but when we talk about looking forward to next year and that you know we're not expecting necessarily to see the increase we have this year the 4.6 percent because of COVID but I don't I look at it as when when this five years is up which is 2022 and that's going to be the end point that actually might be impacted unfavorably by COVID. So how do we get ahead of that you know because next year right might be low and I don't I don't necessarily look at that as improvement because of what we're doing. A lot of it may be because of just what's happening with COVID but the year and when it ends right and that's kind of what the competitive growth rate will be measured off of could be impacted the other way. So how do we get ahead of that. I think that's a really good question. I don't have. We may not have an answer now but it's something we should probably be thinking about because you know should certainly next year things might come down. Looks like everything's on track but because it's like an end point you know and of course we only we keep saying things may shift that could occur shifting you know for the 2022 year 2021 2022. So just something to think about. And I think oh sorry Michelle I just wanted to add about scale because I think scale is really a great entry point into that discussion and thinking about what proportion of the population do we have some I'll use the word leverage over and those are the populations I think where costs can be impacted in in this model per the agreement beyond those. Yeah I think it's a great question but I'm not. Yeah it's just something we should think about. Yeah I think that's why you know although not required by the agreement I think that's why we've shown the growths between each year in addition to the compounded growth so that we can see that kind of movement over time as well. But you're right I mean it might it might be beneficial next year but if you know by 2022 that's the here that's the end point yeah. So okay just something to think about. Thank you. No thanks for the presentation. Other board comments or questions. If not I'll open it up for public comment. Does any member of the public wish to offer comment. Mort Wasserman. Hi just wanted to make a comment about the decline in the proportion of folks with primary care and the fact that it's based on the behavioral risk factor surveillance system. That is a phone based survey system and the CDC and there are some really smart people doing this has been struggling now for years with the fact that more and more people have cell phones and so the it's a random digit dialing system but it might have trouble meeting the proportion of the population that's younger which might actually in fact be the proportion that doesn't have primary care. It's just that this is a really tough thing for a survey research and I would be maybe less confident in this result than in some of the others. That's all. Thank you Mort. Next I'm going to Walter Carpenter with Ham Davis on deck. So Walter. Hey Kevin. I finally got on Microsoft Teams. Welcome. I can't do it through the my main I'm on the iPad. My question is on slide 8 the last one here in 2019 you know TOC 14 percent of total spending on behalf of Vermont residents. I'm just curious how that was spent on behalf of Vermont residents and what it accomplished for Vermont residents. I had a couple other questions too but the board members pretty much asked them. Lindsey you want to take a stab at that. Yeah so what I can say is that that 881 million came from the one care total cost of care 2019 annual and I've included a link in the on the bottom of slide 8 so you should just be able to click on that and it will take you right to the page. You can download that report. That is from their redacted 2021 budget and within those documents one care does detail what per payer contracts the activities that that money was spent on and so you can get a lot more detail from those documents than I'd be able to fit in a concise answer to your question. But it is all there and we did link to it so. Okay. Ham Davis. Can you hear me Kevin. We can. Ham I have a couple of questions. The the main one is this. Can we get can can your data teams get a number that I think is very important. Nobody else may agree but that what I do which and that is the the number of Vermont residents who in the reform environment. Okay. Getting care under the terms of a real risk fixed priced prospective payment system without reconciliation. That would be I understand I'm that's arbitrary but that's that's what I'm asking. And so so what we're talking about is only Medicaid and then we're talking about the number within Medicaid that in fact is within is being managed by such a by such a under such a contract that that contract would have two aspects. One would be to fix the prospective payment in which for the hot for the network hospitals is no more money. Okay. And then there would be a second bucket where the way you were the person the recipient would be able to like get care somewhere else and you'd have to pay for that separately on a fee for service basis. The reason for asking that is that and Kevin's asked this question now both in December and more recently because I think that's the one number that actually has muscle to take costs down. In other words have prospective payments where there's no more money. Can we get a number of as of 20 either 2020 or 2021 21 we're on a calendar basis which is how we work with some with the with some of this stuff. We are now in the set. We're about to enter the second quarter of 2021. And so what I'm curious about is what is the best number of the of the the number of people the best number that we've had of the people that have that are being treated under under the kind of contract that is envisioned as the engine for health care reform in Vermont. In other words a capitated system that is to completely departs from fee for service. That's what that's my question. And thank you for bringing up something that has bothered me forever in that too little of a percentage of the population being treated is under a true perspective payment. We know it's shadow fee for service and that just doesn't cut it. But I'll leave it to the data expert Lindsey to try to answer your question. Well if you can get it Kevin I'm buying you coffee and real coffee not your regular stuff. Lindsey probably can get it right now for you. I'm not sure. I don't want Kevin's coffee to be on the line. It's okay I'm happy with a cheap dollar McDonald's cup as him knows so. So I did see some numbers on that but I don't want to misspeak in this presentation. I'd be much more comfortable running the numbers and giving them back to you Ham. So if you would give us some time to do that we can come up with those. I can say that it is less than the 14 percent here shown in the one care Vermont total cost of care because not all of the ACO is in a fixed perspective payment agreement. But I want to be true to the numbers and give you the actual results. So more to come. We'll pull it together for you. Kevin that's perfectly satisfactory for me. I would like that very much. I have just one sort of a comment. I don't know that any can be done about it. But on the quality side I think that the medical quality is a huge difficult subject which is which and I don't think we're anywhere near where we need to be overall as a system either in Vermont or anywhere else in the United States and being able to really measure that. But one of the things in Vermont is not this issue. I think that we need to and I understand I've been told that it is it is collected. We need to know the number of bi-hospital service area of revision surgeries not read the standard metric is return to the OR or return to the hospital or read admission or whatever you want to call it. In Vermont in Vermont is smaller. Somebody has an operation that doesn't go well almost anywhere they're not going to go back to the same place they're going to go to another one. And that is the single best in my judgment the single best quality metric that you could look at it would actually move the needle on the care that gets delivered. Thank you. I think that was just a comment Kevin. Thanks Ham. Good points. Is there other members of the public who wish to comment at this time. Is there any other public comment. Kevin I think Richard Floskey and Eric Schulteis are raising their hands. Okay. Richard's hand just went up on mine. I still haven't seen Eric's but I'll call on Richard and Eric will be on deck. Thanks Kevin. Can you hear me. We can Richard. So well first I just want to second Ham's comment regarding the movement to perspective payment. And I just wrote a commentary on that in the digger and I just think that's a key to the success of the all payer model. And I really would encourage an effort to create a specific plan in a short period of time to accelerate that movement. So I'll just make that comment. The other thing I wanted to mention and this is not directly related to what you've been talking about. But I think it's clear that there is a continuing undercurrent of skepticism about the all payer model and how successful it has been among Vermonters. And my guess is if you asked Vermonters whether or not they know they're they're aligned with the ACO or what benefit they're receiving if they are aligned I doubt there's five percent of Vermonters that could answer that question. And so my one I guess my concern is communication and I'm not laying this necessarily at the Greenland Care Board but what communication is going out to Vermonters. I mean I think there are very few people that would understand what you've just presented today and what they're seeing what most Vermonters are seeing is continuing increases in their health insurance difficulty in getting appointments with doctors for visits. And so how how how do we describe the impact the benefit of the all payer model to Vermonters in general. And I'm wondering whether any thought has been given to a communication plan in that regard. So a lot of thought has been given in a lot of effort but for the most part without the ability for the resources to do things in a marketing way for the most part information is available that is never accessed. Well I think that means to change. Kevin would you mind if I jump in. Sure go ahead. I would just say I think that is would be a terrific job for the Agency of Human Services who's and it would be quite frankly more appropriate to their role than our role as a regulator. Certainly I think we've done tried to do our best in terms of making user friendly and consumer friendly materials available on our website particularly around the information that we received through the regulatory process. But I think it would be great if others can can certainly take the lead on a communications plan. Certainly our transparency I think might help as well to the extent that people are able to tune into a regulator which you know is is a specialized interest. I'm glad we have folks like Walter and Richard who have that interest. Thank you Robin. Eric Schulteis. Sure this is building off of I think what I heard from board member Holmes or maybe some others. It would be really interesting with this to kind of think about how we can move or maybe we can. I mean that's a question move away from kind of a descriptive study you know and the targets for the APM or you have to hit X benchmark. Two more of a why is this occurring. Why are things going up or down. And I think that's interesting because it could potentially connect to what population health investments OCV is making so that as a state we're spending money where we're at least hypothesizing that it's going to have an effect. Did I lose you Eric. No I think I'm still here. I just that that was it sorry I was wondering why there were silence but I had just stopped randomly stopped talking. Yay to Teams meetings I suppose that's the problem. I think you made a really important point and as a preview of what's to come better understanding the I call them the levers and the stares of both populations over time I hope is going to shed a little bit more light on the cost drivers in each of these for each of these groups and then potentially by by other factors like geography and and age and things like that. So that's the hope. Thank you Lindsay. Comment. Somebody started to say something. That was me it was Michelle. I was just going to say part of what we try to do in these presentations and in the reports they're you know dry but it is you know per the terms of the agreement what we're accountable for and what we are responding to and I think a lot of these other analyses are going to help to inform future reports I think was only two years of data it's a little early for us to start doing that but as Lindsay pointed to you know we're we're getting into some deeper analyses and hopefully we'll be able to expand upon them for 2020 and beyond. But you know just reminding folks of what we are accountable to and and where we are in terms of those targets that are set in the agreement. Thanks Michelle. Is there any other public comment. Hey Kevin. Yes Walter. I want to thank Richard for his comment because that's precisely what I was driving at and we can accentuate we can add more to that is that when you talk to the person the average remonder on the streets or whatever they have no idea what the ACO is because it has never really it has not done anything for them. Prices still go up uninsured co-pays and deductibles still prevent them from care. Constant problems with doctors with claim denials with prior authorizations losing insurance. You know it's the same old problems that this country has never been able to address because it doesn't it hasn't had the will to do it yet. And Richard made some very good points about that. And that's my main concern about the ACO is we have data that goes from here to eternity and back but you know what's a 1.7 or 8 percent. This or that you know it doesn't mean anything when somebody has got a $5,000 deductible ahead of them and needs a surgery or is uninsured and needs a surgery and doesn't qualify for any help or whatever and stuff like that. So thanks to Richard. Thank you for your comments Walter too. I try Kevin. Is there any other public comment. Kevin can I make one final comment another another chance this is here. I hate to say this but I think that you folks should just not feel too badly about about the whole issue of trying to communicate this kind of gnarly stuff to the public. I've been a professional journalist for 40 years and I can I it's my absolute judgment that the we do not not we no longer have a public a press a press structure. OK. They can manage this level problem. It just can't be done. If somebody thinks I'd like to have somebody that knows what they're talking about tell me that that I'm wrong. It's not there's nothing you can do. I think it's just it's just the way it is. Thank you. Thank you Ham. Any other public comment. This is Lindsay. I just wanted to respond kind of overall to a couple of comments that I heard related to all payer model impact and then the how the average Vermonter feels that impact. And what I really heard and please correct me if I misheard was a lot of talk on affordability for the average Vermonter and I love that line of questioning as an analyst and so I really welcome any ideas from public comment on how we could go about measuring affordability now and in the future any data sources you all have to recommend and other and definitions as well because as I'm sure you can imagine it's really complicated to talk about affordability to the person to the plan to the state. So I love the ideas that I'm hearing and as a member of the analytics team I think it would be really great to pursue but would welcome certainly the public perspective on affordability. So just let me think about and just know that your comments were heard. Okay any other public comment. Kevin if I could just this Richard again and I don't disagree with Ham I think the reason the way people will understand the ACO is if their insurance rates stop increasing at the rate they're going or if they can access care better or if they feel they're getting service that's different than what it is today. So I don't think it's about public relations I think it's about outcomes and I think that's what needs to occur. Thank you Richard. Any other member of the public. Hearing none thank you Lindsay and Michelle. A lot to digest but we'll keep muddling along and try to meet the goals. 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. So moved. Second. It's been moved and seconded to adjourn. All those in favor signify by saying aye. Aye. Aye. Those opposed signify by saying nay. Thank you everyone and have a great rest of the day.