 We're going to get started and let me, first let me say that Rep. Donna Hu, it looks like she's not going to be joining us as she has frozen pipes and is dealing with some at-home issues, especially since she's also hosting smoker people in her home at the current time. So I don't expect her to join us if she does, we'll welcome her. So what we're looking to do here today is to take another, is to lay before the committee another important piece of the policy around the Vermont healthcare system. And we heard some overview of the history of healthcare reform in the state of Vermont, some efforts that went forward, some efforts that didn't go forward, just for me to frame it and say that we are in the midst of healthcare reform in the state of Vermont. There's no confusion about whether or not Vermont has moved, has taken significant steps forward in terms of healthcare reform. Some of the efforts did not materialize the way that we're anticipated, but others have taken significant movement forward. And today one of the invited, Ana Bacchus, he's the director of healthcare reform. We're going to ask you to take the lead if you would and maybe even do some introductions of others. But I might also just communicate that he's running late. He'll join us as soon as he can. But I'm going to start by inviting Ana to introduce the framework of healthcare reform where we are now in the state of Vermont. And Ana brings with her a great deal of experience having worked prior to her current position, which I welcome you to discuss, of course, but I've worked for the Green Map Care Board in the midst of actually negotiating a lot of what we're now working with. So, Ana, welcome. Very, very pleased to have you here. Thank you for the record. My name is Ana Bacchus. I am the director. Sounds like aerobics. Yeah. Oh, they're doing aerobics on the roof again, you know. It's warm. Can I hear that? I don't know. Yeah, you're ready to make a change. I was there, you couldn't quite. Yeah. Let me also say, I don't know about others, but with this many people, the room will probably get stuffy and hot. So if you're cold, hang on. But it is also chilly in the room. Let's start. And we'll see if we can. And I think we can do, because that is the potential next thing for someone to give us a hint. Yeah. I'm sorry. Let me start. For the record, my name is Ana Bacchus. I'm the director of healthcare reform at the Agency of Human Services. Thank you for having me here today to talk about Vermont's all-payer model accountable care organization agreement. And also let me introduce the others that are here that are going to be talking about this with you. Mike Barber is from the Green Mountain Care Board. Mike Barber is the chief of health policy at the Green Mountain Care Board. He'll be talking about the board's role with respect to the all-payer model agreement. And Alicia Cooper is the new, Alicia has a new title. Director of payment reform and reimbursement for the Department of Environmental Access. And Michael Costa, who will be joining us is Deputy Commissioner at DBA. Before we begin in exploring the all-payer model agreement, and let me say that we are happy to take questions as we go and to have this be a discussion. And while I'm here talking now, I may turn to the colleagues who are here presenting with me at any point. And then also they all have specific portions of this presentation as we have a long afternoon schedule together. I'm sure you're all very excited. I'm going to take some breaks along the way not to fear, but because there's a lot of material that's really a lot of material. I'm going to try to think about how to put this in more manageable pieces. We're certainly open to choose your own adventure. To begin, I think it's helpful to set some context. And as I understand the committee's been learning and orienting itself about Vermont's health care system. And one of the things that I'm sure you've now heard many times is what the size of Vermont's health care system is. The health care system represents one-fifth of our economy upwards of $6 billion. And as such, it's very large. There are many things that are at play when it comes to health care, health care services in Vermont and how Vermonters interact with the health care system. So I think to that end it's really important that when we're talking about health care reform we're talking about what problem in health care we're trying to address. Defining the problem is very important when we're thinking about what the health care reform initiative is. So here we've outlined a couple of potential problems that people could want to solve in health care. For instance, if the problem is increasing access to insurance for people who need it most, there are different interventions there. There could be interventions such as the ACA. And the ACA's broad health insurance reforms creating the health care insurance marketplace here in Vermont and the exchange. Reducing the rate of uninsured. Similarly the state interventions could include changing state or federal law to require insurance such as an individual mandate. Another problem that is one that I think many are very acutely aware of in health care is the cost of prescription drugs. When we look at the all payer model and we'll talk more about that, the all payer model for Medicare and for Medicaid doesn't include in it health care cost growth targets associated with prescription drugs. So while the all payer model as you'll hear is a very broad reform, it's not addressing all of the problems in the health care system. It's addressing some particular problems. And if I could just interrupt and say several of the issues, problems that you've listed are addressed in other policy decisions that this committee has been and will be engaged in as well from the mandate in terms of access to insurance. The all payer model is a major health care reform initiative. No doubt, but it is about an all encompassing health care reform initiative. It can work in tandem with other initiatives or it may operate on a separate path from other initiatives. If you're looking to solve the problem of the cost of health care growth being too rapid and unsustainable, and if you're looking to solve the problem that we hear about in our health care system a lot, which is a lack of coordinated care, then the all payer model that we are operating in now may be an appropriate approach to those problems. The strategy of the all payer model specifically is to create a more integrated health care system and to do that to move away from fee for service reimbursement because we know that fee for service reimbursement does not necessarily allow providers the flexibility that they desire to ensure that their patients for whom they're providing care receive the services that they most need when they need them. For instance, in a fee for service reimbursement model, taking the time to coordinate care via phone call is not necessarily something that would be reversed. So if that is a critical part of a care plan and it's not being provided for through fee for service reimbursement, that is something that could be addressed through a different model of reimbursement that provides a fixed amount of payment for a certain population of payment. Here in Vermont, the intervention that we are using through the all payer accountable care organization is a statewide accountable care organization model that is aligned across programs and major payers, Medicare, Medicaid and commercial payers, and this is an agreement that is facilitated by this is a model that is facilitated by an agreement that Vermont has with the federal government and we'll talk more about how we got there. When we say that we want to move towards a more integrated system of care and that is our goal for creating an all payer accountable care organization model, I think it's useful to think more about what we need by integrated system of care and I have a video that I'll share today that describes integration of care in a medical model and here in this slide, the Robert Wood Johnson Foundation describes care integration as something more broad, which is balancing clinical care with prevention oriented public health and community based social services to improve health outcomes while driving down costs. That is something certainly that we are hoping for and want to see in the all payer model which is if you provide more flexible funding, how will that funding be used to create more opportunities to balance the clinical care with prevention oriented public health and community based services. In this driver diagram, which gives examples, so all the way to the right are some examples of interventions that can or could improve access to care, that could create more balance and integration in the system and that can improve consumer experience and quality. You see population based alternative payment models in the last example in terms of improving consumer experience and quality and that is because the Robert Wood Johnson Foundation believes that that more flexible funding model can more appropriately meet consumer needs for the variety of care. How did we get to an all payer accountable care organization model agreement in Vermont? How did we decide that we should pursue a alternative payment model that we should pursue specifically an alternative payment model that is global in nature versus paper performance or other enhanced fee for service payments. It took a long time to get here. We began negotiations with the Center for Medicare and Medicaid Innovation in 2014 and those negotiations took two years and those negotiations came on the foundation of other reform initiatives that you've heard about in this committee. Those reforms include the blueprint for health, patient center medical home model. They also included the early ACO aligned shared savings programs that Vermont pursued in part through the state invasion model grant that we were awarded in 2013 and seeing those reforms coupled together and the potential for the ACO model we wanted to see if we shifted more risk to providers if that was something that we could bring to fruition in a statewide model. So like I said we negotiated for two years with the federal government to arrive at the model that we're now implementing. In the model that we're talking about here and how unique is this happening everywhere? It's not happening everywhere. No. The federal government and the Center for Medicare and Medicaid Innovation is very much promoting two-sided risk models for accountable care organizations and that comes from their learning having operated one-sided risk shared savings programs and then venturing into what is called the next generation program for ACOs which is what Vermont's model is based on, the next generation program and the federal government believes and wants to incentivize multiple payers to be a part of these models together because that aligns the incentives. It means that more of the provider's patients are in the model so when things are changing it's happening on behalf of more people and it's less likely that a provider will feel as though their foot is in two canoes although that is certainly still to be expected as there's a transition from fee-for-service to value-based payment models. However, Vermont is extremely unique in operating its current model wherein the payment is shifting in a risk-based model for all major payer groups. There are two ACOs in the United States who are receiving fixed prospective payments from Medicare and one care of Vermont is one of those ACOs. I don't know the name of the other one. We've used already a lot of terms which are like, I have to say, you know what the next generation is and that has the same grant and there's a lot of words that don't really have any inherent meaning if you're trying to understand this without going deep into the history of all of that. Is there a way for us to just, actually let me back up and say, well I think for some folks it's like, we're going to do something else once upon a time and the state was like really big and high on this other whole major initiative we've heard through the health care reform and single payer and all this and that didn't happen. How do we get from that not happening to this starting day? Is that something we can help us with? Sure, and I think Michael can also help with that now that he's here. Welcome Michael. And I'm offering him, Representative Dodger, a chair, not a place at the tables per se but just because I don't think she's coming. If we go back to Act 48 of 2011 and we think about adults, there was a very large piece of legislation and it did many things at once including putting the state on the path for a universal and unified health care system but also creating the Green Mountain Care Board, providing it with payment reform pilot authority and expecting that payment reform pilots would be a way to contain health care cost growth. I mean that if there is not, if there aren't mechanisms to contain the growth of health care then a unified and universal system just like the system we're in now would not be sustainable. I don't know if there's... So we were on a tandem course both pursuing universal and unified system and specifically how to provide for that via tax funding and cost containment strategies. So this is not... So that's helpful actually. I mean at least it's helpful to me, I don't know if it's helpful to anyone else that when Act 48 which we haven't yet actually renewed in detail during the committee we've referenced it but it was a major piece of legislation to set out the parameters of health care reform and state reform what the principles would be. They used to be on the wall before the mold got them and they haven't reinstated them or done some other things still. But that that sent in motion both the possibility of how to pursue universal coverage as well as what we're talking about here is the other path of payment reform that was parallel with that. Yes, parallel path. Which we're still on, which we've continued to move down that path. And that's part of it. So I'm just trying to... I just think it's somehow helpful to frame this in the largest picture where we are and how we've got it. I don't know if Michael's there or anything, but... For the record Michael Costa, Deputy Commissioner of the Department of Health, has access and someone both extremely grateful for this seat and really uncomfortable in the hot seat of the legislature. Having been involved with health care reform for a number of years, it really got back to what problem you're trying to solve in health care. And one was the universal health insurance program, particularly making sure everybody gets an insurance card and you have a way to raise the money for it. And then one of the key findings of the previous administration was that as long as health care spending grows faster than your tax base, you're going to have a significant headwind in funding a single-payer system. And so I think the previous administration said, what problem can we solve now which led to creating a model for a more integrated system of care? And so the all-payer model was what was available as the next step. We've got to have that problem that it costs too much and to try to better align the overall trajectory of health care spending with overall economic growth, while not compromising Vermont's traditionally high-quality health care. And so that's the path we're on now. And I've been pursuing, you know, there are only two real ways to go to health care reform, one's competition and one's integration. And Vermont is all in on collaboration through the whole-payer model. And that's where we find ourselves. Okay, and I'm going to just try to weave some things together as we solve our testimony. Like, if you think back to our testimony from Professor Jessica Holmes in terms of health care economics one-on-one, as you say, the conclusion was that competition wasn't going to get us there. And what we needed to have, and that's one of the basic premises that she was sharing in terms of her analysis of health care economics is that health care is not susceptible to the typical competitive marketplace. So how to get to a place of lowering costs and alternatively, alternatively, this represents how to integrate care and how to work with federal partners through the Center for Medicare and Medicaid Services to provide waivers from some of the requirements of federal law that would allow us to do some things which otherwise would not be permitted under federal law. Is that fair to say? That's 100% fair to say. So that's, I think it's, I've been trying to think about how to ease out and actually solve how we are, where we are in Medicaid before we get too far into all the detail. Yeah, and if you return to Elliot Fishman's original, who is, he was known as the father of the Accountable Care Organization, and he is a professor at Dartmouth. And if you go back to where he kind of originally envisioned Accountable Care Organization, they really looked in some ways more like Vermont's Accountable Care Organization Network looks today, which is an accountable neighborhood, a large continuum of care providers that are sharing accountability for the quality and cost of health outcomes. We have a short video that will show in a short while here that looks at how the federal government articulated through the Center for Medicare and Medicaid Innovation Accountable Care Organizations, and they tended to be a little more medically focused in the traditional medical continuum and not as broad as an Accountable Care Organization neighborhood concept as we see here in Vermont today. And I think that's important to appreciate because the idea behind the Accountable Care Organization is that providers are coming together in a network to be mutually accountable for the population that they share care for. And some of that quote coming together in integration would run afoul of federal law. Correct. And I think these are key important pieces that this is the waiver and the federal waiver is what allows Vermont to do some things which otherwise would be seen as illegal. Is the Innovation Center that really can facilitate these models? And that's where the Innovation Center has its particular power, the Medicare and Medicaid Innovation Center, which was created by the Affordable Care Act in order to allow for the federal government to test alternative payment models, specifically ones where providers were cooperating and integrated without having to have those payment models approved by Congress. Am I a good question? It is. Yeah, and I think it's so I just want to put out there the way that I am thinking about Act 48 and about ACOs and Act 48 was, as the chair mentioned, had five principles in it of human rights principles. Transparency, accountability, equity, participation. I always forget one equity anyway. They're all critically important. And so when hearing about the Accountable Care Organization, I think it's important to continue to remember what all of us that worked towards the Passage Act 48 in 2011 were hoping for. And I do believe as a person who works in the healthcare system at the bedside, I do believe that there are benefits for Accountable Care Organizations, and I also want to keep, I do keep in mind that, for example, the slide that says the problem we are trying to solve is to increase access to insurance for people who need it most. I would say the problem we are trying to solve is to improve access, to increase access to healthcare, not necessarily insurance. In this time that we're in now, yes, it would include increasing access to insurance. So there's different fundamental differences between the intent of Act, I believe, of Act 48 and of the ACOs. And again, as someone who practices in the healthcare system, I have noticed benefits of Accountable Care Organizations. And as I continue to work in this role and listen to testimony, I am going to be concerned about those five principles that include accountability and transparency and participation in particular. And I know the Green Mountain Care Board has oversight, but in what meaningful way. Because the ACO is actually has major control over public, state and federal parts. And as we, I appreciate that comment, because as we've worked through the process of going through the two years of negotiation to see what would a Accountable Care Organization model look like for Vermont in Vermont or to create an agreement with the federal government, that allowed Medicare to participate on Vermont's terms. And in those two years we kept the legislature updated about that progress and what that program could potentially look like. And we shared term sheet proposals and framework for the program. And upon seeing that, this committee felt that it was important that the legislature grant authority for the state to enter into this agreement, only if the agreement was consistent with the principles of Act 48. And so that's there here on this slide. And then it also, in that same legislation did require the oversight of the Green Mountain Care Board, which might can elaborate on here as well. Thank you. And so I'm just going to add as well that we may not be done with holding, there may be other initiatives that outside entities or individuals or members want to propose that enhance accountability, enhance transparency, enhance the principles Act 48 as we're going forward. And those, we may take up some of those proposals and we may implement some of those proposals or pass some of those proposals. But they're not, but they're proposals that are trying to work within the framework of Act 48 and within the framework of the waiver proposal, which is the policy of the state of Vermont currently. It's not a question of shall we have this policy or shall we not have this, shall we move forward with this reform at this point in time or not? I mean, if we wanted to entertain that question, that's a very, very large question. Currently, I guess I'm just wanting to say currently the all-pair model agreement, which we said must be consistent with the principles of Act 48, is how we're moving forward in an agreement between the legislature, the executive branch, to try to try through these processes to reduce and impact the cost. And we're not there yet. We're very much in the process. It's not like we have a finished product. We are very much, in some ways even at the beginning, part of the midpoint of a process. So that's what I think times are usually. January 2019 marks performance year two of an agreement that contains five performance years. So we're in the beginning, I think technically we're in the beginning of implementing this agreement. And the agreement is between Vermont and the federal government, our partners at the Center for Medicare and Medicaid Innovation. The agreement includes signatories from the State of Vermont, the Governor, the Secretary of the Agency of Human Services, and the Chair of the Green Medicare Board. The agreement allows for Medicare to participate in Vermont's terms in many ways in an alternative payment model and allow for Medicare to pay accountable care or innovation in Vermont in a way that is aligned with other pairs participating in Vermont. That is the chief advantage to our state that this agreement allows for us, is Medicare to participate by Vermont's terms. And that, to put it in really, really layman's terms, it's a big deal. You can't just decide that we're going to do this and have Medicare participate. Medicare is a federal program and there are those who in other states, in fact in conversations I've been part of over just in the last few days, there are other states are going, how do you get to do this? How are you getting to do this in Vermont? This is not something that just happens. And so we've yet to see if this is going to have the full impact that the hosts that were set out. But that is part of the framework that was negotiated and was a significant part of the negotiation that meant that we in fact in Vermont could help Medicare as a part of this new model. That's right. And in addition to Medicare's participation in the model and in paying differently, and Medicare has been paying fee-for-service since 1965, and it's paying in a radically different way in Vermont and in one other place that has an accountable care organization that is receiving fixed perspective payments. So it is a very big deal in terms of shifting the paradigm in our healthcare system. Medicare through this agreement is also, we were able to secure funds for Medicare to continue to participate in Vermont's blueprint for health. And that is through the accountable care organization as the mechanism for funding that ongoing investment. And that was another important principle that we held very tightly as we were working through the negotiation because we believe that in a system that is shifting the incentives and emphasizing well care rather than sick care that preserving our patient-centered medical home program was extremely important. So we've got to have ourselves a trip to scheduling that's what I think about it now. We haven't really talked about the blueprint for health. And I'm wondering, maybe I'm fair on a 10-second notice, is there somebody with either Ena or Michael be willing to kind of just do a brief process of what the blueprint for health entails? Sure. In a way that can be easily adjusted. Because it's a piece of what Vermont has been undertaking for some period of years now. And you were saying we wanted to maintain it, but what is it? We wanted to maintain Medicare's participation in it specifically. That's what you were saying, yeah. It is a part of the Department of Vermont Health Access. I think it's appropriate for Michael to describe it. Mr. Chairman, at a very high level, the blueprint for health is the Department of Vermont Health Access. It is the all-payer innovation arm of health care in Vermont. It's an overly bureaucratic way of saying that. What the hell was that? I'm sorry. Long story short, about 13 years ago, people came together and said, hey, health care is probably going to need to do something about it. And there needed to be a spot to work on actual payment delivery system reform. Can we change the incentives for how people care for people through different payments? And can we create a learning collaborative where people can learn how to care for people in a different way? Over the last 13 years, Blueprint has basically created a network of just about every primary care office in Vermont and offered them support through community health teams and other learning opportunities and a whole bunch of per-member, per-month payments to try to try things different. They come up with things like the Women's Health Initiative, public spoke, just a variety of ways to get practitioners to think differently about how to care for people. And the way that I kind of explained this, but hey, the Blueprint and the ACO, the Blueprint is like the phone. It's the operating system for healthcare reform in Vermont. It's a bunch of practitioners that listen to each other and work together. And the Blueprint provided them with all sorts of data about their practice that they didn't have before. And then the ACO is kind of like an app on that phone. It's trying to take those relationships and work harder and faster on them. And one big difference is Blueprint provides practice level data. Hey, we noticed that 10% of your practice has big problem diabetes. Let's work together on that. Whereas the ACO provides that same type of information, but on a member-by-member basis. And so I have come to believe through my two years at Diva that there's something really special about Blueprint and it's way more effective than the sum of its parts because it is if you have a good idea, you can drop it into this network and basically get a whole bunch of primary care docs working together in a different way and working together on things that are usually a little bit outside normal primary care, mental health, substance diseases, et cetera. But it's just a fancy word for the level of collaboration that exists among primary care docs and Medicare participates in that with some payments. And the all-fare model, one of the big negotiation and logistical challenges was making sure that Medicare still paid into it. And we made the argument to them that it would be a very funny time to stop paying into it and we're about to really go after primary care based health care reform. Part of the Blueprint, as I understand, the goal of Blueprint was to have virtually all Vermonters have a medical home. It's a term which gets thrown around here. It's basically that means everybody has a primary care physician which is the place, the focus of where they would be able to go to seek other services to whether it would be an ongoing understanding of what their care is and hasn't been. And that's a part of what the Blueprint for Health has been working toward achieving. In fact, the technical way in which the money has paid to us is taking what used to be called the multi-payer advanced primary care practice project. Basically, demonstration, thank you. That cures it up. That was the federal program that allowed Medicare to pay into primary care practices of the month. So Medicare and private insurers and Medicaid would do that together. And we said to them, hey, you need to maintain that funding as we go and take these care based reform. And the Blueprint has, I think, very unique and important about the Blueprint that has these things called community health teams. And the community health teams support the patient-centered medical homes and they provide connections from your patient-centered medical home to other services. And it varies by community, but those community health teams are a critical component in facilitating connections to nutrition services to, in some places, even economic services, facilitating connections to chronic disease self-management programs, things of that nature. So to try to bring us back, part of what you were starting to say was that, when I said, oh, who tells me the Blueprint, is that part of the negotiation with the federal government around this large waiver that allowed us to include Medicare payments was that we're already doing some of this in a significant way in Vermont through what we call the Blueprint for Health. Let's not, let's make sure that this builds on that rather than become something separate from it and it gets to build on the Blueprint work. And I really do want us to hear from folks who are working at the clinical level with the Blueprint opposites. The one observation I would have that needs help at this point in time is that I feel like the public policy conversation about this has mirrored the internal deal of business conversation about this. When we started working with an accountable care organization, our team said, well, the ACO is now working in this field. We're going to get out of this field. And we've said to them, no, no, no, no, no. This is about collaboration. And so same in public policy. I think in the case of the all-pair models first analysis, well, the ACO and the Blueprint are double parts and we responded to people, no, we envision a strong collaboration that builds on Vermont's foundation of health care reform. It's both and, not either or. It's a real struggle to tell that story and make it work. But that was very much a part of what led us to have a successful negotiation with Vermont. It had this infrastructure, something that it could build on as risk for total cost of care was shifted to providers. What tools did providers in Vermont have to be able to promote better health for their patients and live under that target? Can I name what I think is one of the challenges in Vermonters understanding all this? I mean, maybe us, to start with us and then Vermonters generally. I think the Blueprint is pretty much invisible to Vermonters. I don't think most Vermonters could say, I just, my physician participates in the Blueprint for health. I just, I don't think it's a case. And yet, as you say, many or most Vermonters who are seeing a family physician, your family physician is actually a participant in this piece of reform work around health care in Vermont. And they're receiving actually some payments to facilitate them and participate. But I can tell you, I have never once heard my family physician say anything to me about the Blueprint for health. Now, maybe that's entirely appropriate. But I think a lot, when we start to explain what's being put in motion in Vermont, I think there are certain aspects of it that because they're not visible to the average Vermonter when we start talking about it, it's like, what are you talking about? Why aren't that? And I think that's, and I'm going to just name that as a challenge, which I think is an ongoing challenge for some of us as we look at other parts of the all-fare model and the parts of the ACO. If the person themselves doesn't know in some way that their health care is impacted or participated or benefited from some of this, this all seems like a foreign piece of that. I don't even know what it is. I just have a quick clarification question. So in your explanation of Blueprint, you said the Blueprint shares data, practice-level data, and the ACO does member-level data. What is the difference between a practice and a member? So the Blueprint, the Chairman's point, is in 137 of 149 practices, and they might say to, you know, let's call it shell burn pediatrics. Hi, do you know, you know, you have a panel of 2,000 kids. You should know that the data tells us that a quarter of them are at risk for obesity. We should think really hard about strategies to work on obesity for those kids. Whereas my understanding of the ACO program is that... That's not what you're just describing. It's the Blueprint. The Blueprint is historically-enabled care through that type of data. And on the ACO, it gets more to, instead of those 500 kids out of 2,000 more, we're responsible for the total cost of care of John Smith or James Smith. Where our tools tell us that John or Jane, you might be at risk for this, you might think about these specific strategies for John and Jane. I want to make sure the ACO speaks for itself. That's the distinction that we think about as a payer into that program. And to that point, we didn't have everybody go around and introduce themselves, which I might still do, maybe after we take a break. Is there anyone in the room here from one care? Lucy is here. She stepped out. Lucy is here. Okay, great. Because I think I was trusting that someone from one care would be in the room for this conversation. I'm sorry, Woody. I was just going to ask a question. Woody, you're going to speak up just a little bit because I'm not sure everyone in the room can hear you. I was just going to ask a question. You asked it. Ask it again. I'm not knowing what blueprint is. Why do I care? If I have my own insurance, my own private insurance company, why do I care? That's a very good question. That's a good question. What is that? I mean, unless it affects me financially, I mean... Or from your clinical care? Perhaps. You wouldn't care about that. I mean, I can take a shot at it just in terms of the example that was just given. If you're seeing a primary care physician, and so I don't know the examples of all the things that the blueprint are working with, but let's say you're not Woody of your certain age and certain gender, but that you were a younger person that fit into a panel of what you were talking about and were at risk for obesity, the blueprint would be taking your primary care physician's information and saying there's a way within your family practice that care could actually be improved for some numbers of your patients based on our analysis of this data that you've provided and that we've been collecting. And I think for some family practices, part of what has been suggested is that simply knowing that kind... Most practices don't analyze that kind of data on a repeat basis. And that sometimes simply knowing that there's this disparity within a certain part of your patient care. People call them panels, but that doesn't really work. But then you're able to think about how to tailor some additional... And then next time you come in and you fall within that percentage, that might actually provide them with more opportunity to provide an intervention. But if my primary care physician is up on things, why does he need a blueprint to show him the way for my health? I think, Mr. Chairman, that of course would be instructive to have those primary care docs speak to this. What we are told... That was a very good question, Woody. The two ways in which we think of it are, one, the same way as the chair, that this is going to enable better clinical practice, be able to distribute models of healthcare for the right people at the right time. And then the blueprint evaluations over time have indicated that if you give the right care at the right time, there will be an organization of healthcare services which keeps cost down for your insurance. And can reduce hospital admissions as well. Which is in... I don't think any one of us looks forward to a hospital admission. And so that's... When the blueprint... We'll have the blueprint talk to us more about that. I think your questions are dead on. Are you talking about tweaking something that already exists or is there something that's already in the program that the general care doctor doesn't recognize or realize? I think you're one of the other states that is talking to the chair about health policy. One of the things that you probably need for this model to work is a well a really strong network of primary care doctors that are used to working together and one of the advantages in Vermont is that we did not need to invent that. It already existed because of the blueprint for health. What you're saying, Brian, is right on. It's tweaking the all-paramount to make the connection. The all-paramount agreement is actually in part a way of tweaking, but significantly but tweaking something which has already been put in place in Vermont and that's the blueprint for health. And I'm going to turn to you all because I don't have the kind of detailed examples, but people sometimes refer to the blueprint as the chronic care. For those of us who have chronic health conditions, would you? Sometimes understanding how to work with people with chronic conditions it's not like second guessing your family position or saying they don't know what they're doing, but it's like how to with a broader picture understand what are some of the things that we're learning that could be done to help prevent you from to help intervene for your specific health and the health of the whole practice with a goal that fewer times would you get admitted to the hospital because it would be an earlier intervention that would be done. And not by telling the doctor you don't know but by saying hey, what about this? Have you thought broadly about this? And there's research that shows that and one of the things I've learned in this committee is there's research that shows that physicians by and large want to they want to do the best of course they want to do the best for their patients and when they are given data or information that something going on in their practice is an outlier they immediately try to figure out how to bring it in line and that's true for a lot of different parts of health rather than One example that I think could be helpful in how the blueprint works is that some primary care providers have chosen to become spokes and spokes are primary care providers that are providing for medication assisted treatment for their patients and in their patients are substance use are opioid dependent specifically and that's something that's changed over time the number of people who are opioid dependent and that's something that wasn't always in the scope of practice for primary care physicians and the blueprint supports those primary care physicians in providing nurse assistance and the community health team that works with the patients who are receiving medication assisted treatment for opioid dependence I think that's one way that medicine has evolved over time and the blueprint is stepping in to help primary care practitioners in this state Just kind of push it back one thing that really helped me with the blueprint is really talking to the doctors because it really is an operations thing and understanding how this work how they're utilizing it and how they're using it with all payer it really is more there is the care management piece of it but I think the whole operations is more financial than a risk management which I think might help provide health financing model and then we can talk to the blueprint another day with people on the ground that may be the most new system no that's helpful I think that's helpful Ben because this is talking more about the financial incentives to change the incentives for care from fee for service to more structural stuff which I think is very important and I would just say briefly I think representative Smith points are really good one where you sit determines what you see when we were negotiating with federal government about this they said to us we don't want to partner with people who can do things we can't do and two we don't want to give you risk you can't handle the blueprint for health is already an existing multi payer primary care collaborative we don't have that other places you can do something we can't do and the fact you've been doing this for a decade means that we think you can handle primary care UV in Vermont can handle primary care based innovation because we're going to pay you a different way with Medicare which is a really big deal and we want to we're going to do that for the first time ever we're going to make sure the state that we deal with you can probably handle this and so understanding to representative Jicklin's point the true operations the blueprint is important because it's about how primary care gets done on a daily basis all across Vermont and the ACO tweaks that and builds on top of that it's not a wholly new thing it's more incremental improvement rather than some revolution how we do that like tweaking without spending additional money you don't need to spend do I just make sense or not well we are spending some additional money but spending just the additional money that makes sense in terms of what we're trying to achieve between that work I think that I think that was a really helpful point and the model is specifically the test of this model is if you change the incentives will there be delivery system changes that allow you to live under a new financing structure so the model doesn't work unless there is delivery system reform and delivery system change but that change is incentivized by the payment change so specifically the model allows for there to be contracts between payers and an accountable an accountable care organization in this case in Vermont it's one care in Vermont that's the accountable care organization and the payers are three types of payers the three major payer groups yes Medicare and Medicaid are each their own payer but commercial is a group and so through the model the accountable care has a contract with the accountable care organization and it's actually through that contract where the waivers are granted Vermont doesn't have any waivers as a state the accountable care organization has waivers via that contract with Medicare it's a technical distinction but it's an important one those waivers allow for there to be changes in how the Medicaid program changes to the skilled nursing facility and additionally allows for a home visit for persons who have been discharged without the home bound requirement for that visit the Medicaid program has its own contract with the accountable care organization and commercial participating commercial payers have contracts with the accountable care organization and all of those contracts are looked at by the green mountain care board and the green mountain care board youth is required to assess how they align are there alignments in the paying payer mechanism are there alignments for quality measures across those three groups of contracts and then has a network of providers that it works with the accountable care organization is paid and this is at a very basic high level is it receives the alternative payment and then provides for that in their participating network of providers Michael and Alicia and Mike may talk about how that works differently by different payers and some of the variations to that it's not as straightforward simply an alternative payment to the ACO but I'll let them get into those details does it make sense to review a quick video about accountable care organizations we did this with your committee last year okay great and then maybe after we see the video maybe there's questions after the video maybe we'll take a break yes that sounds great can you hear it you might want to put the microphone yeah well that's can you put your mic in your speaker it will actually affect our experience true we do this the microphone just leads to the microphone to record our microphone in the first century so you can see it right does it have a closed caption on it the accountable care act isn't just a new way to get health insurance it also ushers in every approach to care meet the ACO an accountable care organization is a network of doctors and hospitals that shares financial and medical responsibility for patients the goal is to coordinate care and eliminate unnecessary spending Medicare sent these up around the country and insurers have too in the health system today patients are usually responsible for coordinating their own medical care someone with heart disease they see a primary care doctor a cardiologist and maybe even a heart surgeon but the doctors might not talk much so they could order repetitive tests or prescribe conflicting drugs that isn't good for the patient and it's expensive it's also not the way things work in most other industries if you don't imagine that to fix it you have to schlep to the transmission whisper the battery bearing the timing belt tycoon and the piston professional each to an only look at their piece of the car and not think about how the cars work together that makes no sense instead you go to an auto garage where an organized crew works together to make your car run again an ACO brings that kind of coordination to your medical care your doctors, imaging specialists all work together and share information to figure out the best way to fix you up and keep you healthy afterwards what's in it for the ACOs? ACOs that save medical care money get to keep a portion of that savings if the doctors and hospitals can show they're doing a good job keeping people healthier so are ACOs working? well the jury's still out it's unclear how much money ACOs save and some organizations that try to form ACOs have quit there are also concerns that ACOs could reduce competition and lead to higher prices wait a minute, how is this different from an HMO? ACOs have been accused of being health maintenance organizations in disguise both depend a lot on a primary care doctor who coordinates care but there are some major differences patients in HMOs are covered only when they see doctors that are part of the HMO in a Medicare ACO they also see doctors outside ACO shouldn't we worry that an ACO can save money by tight corners? ACOs get rated on a list of quality measures to make sure no one skins on care people need these measures don't get track of all aspects of care but the goal is to get ACOs financial incentives to keep people healthy instead of just treating them once they're sick want to learn more? go to the address on the screen so before we take a break I want to make two points that I think would be helpful first one care as I said before one care's network is larger than doctors and hospitals it includes a broader continuum of care I'm not exactly sure if I could get back to my slides or not but I will do my best because I have an illustration of that and second in the summertime Medicare published its first results on the next generation ACO program so there was a cohort of next generation ACOs that began in 2016 so Vermont's not included in that cohort and they found that those ACOs that were taking on risk that they did generate savings for the Medicare program and that's a difference between those ACOs that were participating in the shared savings program and the next generation program where there's significantly more risk shifted on to providers and along with that more flexibility in how they deliver care so I wanted to provide those two points after the video and prior to our break you have the findings at a glance from the next generation program and then here's an illustration of the types of providers that are in OneCare's network which I also thought would be helpful so Lucy I think you had a question somewhere along the way yeah I have two questions let me just suggest we're not going to try to understand all of OneCare right now I think you should learn it's definitely here from OneCare yeah we'll be hearing from OneCare but I'm just saying that's a pre-emptive question my first question was you were saying about the ACO having waivers as opposed to the state of Vermont having waivers is that any ACO in Vermont or specifically OneCare so if another ACO were to form a Vermont would they have to go through the entire process all over again of getting waivers? that's a great question OneCare through it's agreement with the federal government and now they're not actually operating as a next generation ACO they're operating as a Vermont Medicare ACO initiative ACO and so they have a contract directly with CMMI and through that contract that's where they can avail themselves of those waiver opportunities but they are available to other next generation ACOs if there were other ACOs in Vermont that wanted to participate in this program they would simply well it's probably not simple they would need to be certified by the agreement on care board they would need to participate indicate that they were wanting to participate in the all payer program and then they would need to meet those requirements and then they through a contract with Medicare would have this alternative arrangement but no we wouldn't have to negotiate a new model when we negotiated the model we didn't know there would be one ACO we didn't know there would be 10 ACOs so would they so if a new ACO were to form were the waivers was that something that happened with at the point of the model negotiation or was that something that OneCare would through specifically when they were forming? The federal government is offering these waivers through the next generation program regardless of Vermont's model however Vermont's model allows these next generation waivers to be incorporated into our programs as well and then my other question was the video and then I also heard you reference the evidence for the ACO being the lack of communication between the need for the ACO being the lack of communication between different types of doctors and different people who are out of care for a patient evidence do we have in Vermont of the lack of communication like how do we know that in Vermont our doctors are not communicating well already or compared to other states do we know how we're out of that or how do we know that there is a need in that way? That's a really good question I think that how we experience care as individuals may give us that evidence to a degree I certainly have experienced some care myself that I wish was better coordinated and where I wish I had to be the middle person but how we compare on that to other states is a question I'm not sure I have the answer to I only ask because my experience has been I just feel like anecdotal evidence is not that helpful maybe because my experience has been having great experiences with coordinated care between my primary care physicians and I'm sure everybody has a different ground I'm just curious if there is any sort of a measure or how we know the background Well Vermont has a we also have talked about and this committee has heard about I believe how well Vermont's healthcare system does perform so I think Vermont's healthcare system is a very high performing system and we have a lot to be very proud of here with many good outcomes at the same time where we rank top in the nation for our outcomes we're still ranking in the middle lower end of the path with other developed nations on our outcomes so we know that there's still room for improvement I don't want to monopolize I think my only point is it just seems like the effectiveness of the model would be dependent upon how effective we would be at the start of the model so it seems like the more effective Vermont is to begin with perhaps the less there is to improve through the model which is why I was just curious where we were getting our information that speaks to some of where our targets came from which I think Mike will share more after the break but we have these high level population health outcomes and those are places where Vermont and those are specifically places where we're looking to improve through the model and those are places where Vermont does not have as good of a status of outcomes such as reducing deaths due to suicide, reducing deaths due to drug overdose I have a clarifying question because I do want to be clear about it I think it's important so the one care is a private for-profit entity that is using managing having public state and federal money through it and corollary question is where else does this happen? One care is a entity that's owned by two nonprofits that are the founding partners of one care in Massachusetts there's an example in Massachusetts Massachusetts has a medical ACO program as well where ACOs are working with the Massachusetts Medicaid program to accept alternative payment and so those are Medicaid public funds that are going to those ACOs there that's one quick example that I can think of there are likely other Medicaid ACOs accountable for the ACO itself though I know the hospitals within the ACO are not-for-profit but the accountable care organization itself is that not-for-profit it is not for-profit but that's a conversation I think that you should explore that more with one care because I think that they would be best capable of talking about that. There's a question that some of us have raised previously as well and I think it's it's not as simple as the corporate structure being the shareholder structure of what we when we say for-profit it's a different corporate structure but I think that one that we should talk more about than we will. The Green Mountain Care Board also looks at that in their ACO certain vacations. My understanding is that Michael Barber the Green Mountain Care Board and I do think the one care should speak to this when they come before you but my understanding is there were some challenges to setting up the ACO as a non-profit because Vermont law prohibits non-profits from making distributions to the providers essentially in this case so they had to be set up as a limited liability company I just wanted to note that while the ACO is owned by Dartmouth Hitchcock University of Vermont Medical Center a group of 19 members, board of managers that is representative of one care's broader network so they've got independent primary care practice representation of skilled nursing facilities designated agencies and so on so that is something we look at at the Green Mountain Care Board and the certification which I'll talk about And absolutely when we have one care for me and I think there's some other that question was frankly the question I had early on trying to understand why would we be structuring this way and I'm not sure I can fully articulate it right now but there are reasons other than it's a for-profit in order to generate profits and I think that we serve ourselves well having down-speaker but also for us to ask the questions so we understand what the structure is all about so I'm going to suggest that we do take our break right now and how about we let's come back at what we're going to do let's take break to the corner we need a good strip okay so before we get started again with our next witness I would like to ask those who are in the room to just go around introduce yourself by name representing a particular group that's useful for chair just in terms of the resource and also who's interested in what we're up to today so let's do that good afternoon Michael Pauston Maddie Champa legislative intern Dale Hackett grandfather three I'm going to suggest you go Dale Hackett consumer rather than just Dale Hackett consumer you should claim her I'm sorry why am I embarrassing you too much because you're in there a lot I'm going to say claim your role okay that's what's important Alicia Cooper department of non-health access I'm a little slow so I'm going to turn on Ingrid Mulgrain like representing some non-profit health care suggestions we need a health network spacing sorry that's a start yeah that's the main one thank you Mike Fisher healthcare advocate I'm Ian from this Walter Carpenter I'm with Vermont health care for all this committee room has been my winter vacation home for about 10 years now since that 48 days winter vacation home winter vacation home right here Ian Hackett American Nurses Association American Nurses Association for the moment Susan Aranoff the Vermont Developmental Disabilities Council and I just want to point out that while we're a state agency and I am a state employee Developmental Disabilities Council is unique every state has one we're entirely federally funded community state dollars and income support sometimes and we're supposed to represent the consumer and family voice so people with developmental disabilities and we have a lot of interest in what's happening in health care reform especially Medicaid Laura Pelosi I represent a number of providers who participate in the all care model and ACO the Vermont Association of Hospitals and Health Systems the Vermont Health Care Association which is your skilled nursing facilities and also they add a home health Lucy Garrett with Downs Rackham-Burton represent one care for a lot the home health home health agencies and also hospitals the retreat Sprayfield You may have the association Great, thank you Appreciate it So I think we're going to give the microphone to Mr. Barber Thanks for the record Michael Barber being on the care board trying to speak up from that pretty quietly So Ina had mentioned some of the benefits of the all care ACO model in terms of Medicare's participation some enhanced flexibility that comes with that some Medicare genetic waivers that Medicare beneficiaries can avail themselves of as well as additional continued blueprint funding I will maybe touch on those but before I do I wanted to get to accountability that comes with that flexibility and Medicare participation So the requirements on the state and the all care ACO model agreement So this slide tries to tries to summarize it very generally In the box on the left you'll see that the agreement includes both cost and quality targets with respect to costs there are targets for the amount that spending on certain services will grow both for Medicare and all payer beneficiaries All payer beneficiaries includes most Vermonters most Vermonters with insurance with respect to quality the state is responsible for meeting targets on 20 different quality measures which lead to evil or arching population health problems for the state including access to primary care reducing deaths through suicide and drug overdose reducing the prevalence of morbidity and chronic disease kind of talk about each of these a little bit more in depth in a minute and then moving to the box on the right the state is also responsible for ensuring that ACO programs in Vermont so Medicare commercial programs are aligned with one another in certain key areas and finally the state is responsible for over the life of the agreement steadily increasing the scale of the model of the number of people who are in the model both scale and alignment are important to ensuring that providers have strong consistent incentives to make changes that will reduce cost and improve quality so basically the goals on the right hand side of this slide are important to achieving the goals on the left hand side in terms of increasing cost and improving quality this next slide provides some more detail on financial targets in the agreement so for all payer beneficiaries again most promoters the target that the state is trying to achieve is a compound annual growth rate of 3.5% which was intended to tie to the historic rate of growth in the state's gross domestic product so try to bring spending on these services in line with the state average gross domestic product for Medicare beneficiaries the target is a compound new annual growth rate of at least 0.2% less than projected national Medicare growth so it's tied to projected national growth as opposed to actual national Medicare growth that was important to the state so that the state would have an idea of what the target is in advance performance on these financial targets is calculated over the five performance years of the agreement with the baseline being 2017 spending so because it's a compound annual growth rate it reduces some of the impact of volatility so we could miss a year and still get our target because of the compound annual growth rate using that there's a question in terms of you say at the very top all payer growth target of 3.5% less what is captured within the all payer growth target what are we actually measuring measuring spending on certain services they are generally Medicare Part A and Part B type services so your traditional Medicare services and their equivalents in Medicaid and commercial so not pharmacy not some other services but a significant portion of healthcare spending and are we measuring what those services that are each given year provide through the ACO are measuring all healthcare costs in the state of Vermont regardless of whether provided through the ACO so for the all payer target of 3.5% or less that is all healthcare spending regardless of whether it's in the ACO for Medicare it's a little bit more complicated so for the first two years of the agreement we are only measuring and held responsible for the growth within the ACO and then depending on what our scale is in the third year we could be responsible again for only ACO attributed for all Vermont Medicare beneficiaries and then for years 4 and 5 on the Medicare target for all Vermont Medicare beneficiaries can I just can I just chirp up and say that when Mike said all when we are measuring all spending he still means all A and B type spending he does not mean more than that ever all the slump would be the equivalent of part A and part B can you say what A and part B and part B just you mean just in general part A is hospital hospital services and part B is like traditional physician services yes in the system or not in the system or in the network or not in the network earlier we saw some numbers about how many participating providers that were doctors, practices, hospitals and I think that there were 13 hospitals out of 14 if I remember correctly I'm curious about what percentage of the population essentially is covered through this model or the provider or the network that's all right there's a slide later in the presentation cover scale basically how many people were in percentage wise I think it's an actual number so I also wanted to note that the agreement provides some flexibility in terms of unanticipated events such as changes in Medicare law or localized health or economic shocks things that might impact the state's performance on these measures can be taken into account we had a sub-nepidemic of some type which would throw the whole public care system into disequilibrium those kinds of things and while these are the targets that I just mentioned there are also corrective action triggers those triggers are when basically CMS can point to us and say there's something wrong here we need to we'll never pay back money to the federal government like if we don't hit these targets we'll never go money back to them but if we go above corrective action triggers then we can be required to submit a corrective action plan to them saying how do we get back on track so the corrective action trigger for all payer beneficiaries is 4.3% compound annual growth rate and for Medicare the trigger is if compound annual growth exceeds national projections by 0.1% on that the federal government speak I think there's a 3 there's like the green back care board there's the agency or the agency of the agency of services sorry I had a very late one last 5 minutes they had my great back in check so there's the agency of services the green back care board and the governor's office they're all they're all signature ones to the agreement is there a point of responsibility in terms of the CMS or whoever saying there's a corrective action involved do they approach the green back care board do they approach the agency of services the governor's office or I'm not sure there's a specific process it does have some specifics about how a corrective action plan will be triggered but seriously we report the green back care board reports to CMS and I'll get to this in a minute and all these measures and so that would be the initial point where we would identify that we're not we're above a corrective action trigger here and then we would need to work with all the signatories AHS governor's office reporting to them so the next slide covers the quality frame of the agreement which acts as a check on the model's financial incentives to reduce costs so as I mentioned there are 20 measures to state this responsible for under the agreement in negotiating those measures to the state advocated for ambitious but realistic targets on measures that address key state priorities so pulling from the state health improvement plan for example the state also considered collection burden advocating for measures that were already being prioritized and collected in Vermont as well as measures that relied to the greatest extent possible on claims data so as to minimize the need for intensive medical records so there are targets associated with each of the three population health outcomes these these outcome measures are measuring the health of all Vermonters regardless of whether they're in the ACO or not and then supporting each of those high level goals there are healthcare delivery system targets that evaluate the ACO's performance and the quality of care received by the people who are attributed to the ACO these measures can be payer specific for example with just Medicare and then there are a number of process milestones which ensure that the state and the ACO because these measures cover a broad range of issues that may be the state some of which should take hold on for measuring whether the state and the ACO are doing things that will move the needle on the broader population health measures so for example one of the process milestones for reducing the prevalence and morbidity of chronic disease is achieving the 25th percentile as compared to health plans nationally for people the number of people who are receiving asthma medication so fill in from those up to the broader goals of the model somebody was interested in another time they could find more detail on yeah if you don't provide too much detail but you're saying that that level of detail is there because I'll just mention because the suicide issue is a great concern in the interest to many people who don't know anything about it but they care but they care about suicide anymore and there's going to be suicide prevention day and there's going to be initiatives and so the link here is that this has to be one of the large population measures that is part of this model that people should know about but it may not so the next slide shows the targets in agreement for sale and that's the number of children in the model who are attributed to an ACO that's in the model but as you can see they are fairly aggressive they were developed with the idea that the three ACOs then operating in the state would join to form one which obviously did not happen but by the end of the models of performance year 5 2022 for all beneficiaries the target is 70% for Medicare scale target for beneficiaries so what are the questions that might be important to understand the facility at this moment but it's like where are we in the scale process and if we're not at scale is it possible to get the scale in one place what are the steps to get there there is a slide that shows our expectations and then as I mentioned one of the other requirements in the agreement is that we ensure that ACO programs operating in Vermont align to the extent possible on some key areas try to list those areas here so attribution methodologies which are basically used to determine the people that the ACO is responsible for second programs have to align in terms of the services the ACOs will be responsible for the expenditures that will be included in determining how the ACO performed under the all payer model we want we want the services the ACO is responsible for to align as much as possible with the services the state is responsible for under our all payer model agreement so again part A and part B type services and then third programs have to align in terms of quality measures the ACO will be responsible for we also want these quality measures to align as much as possible with again quality measures that the state is responsible for under the agreement and then fourth ACO programs have to align in terms of payment mechanisms or basically how the ACO and the ACO providers get paid in risk arrangements so the risk that the ACO has expenditures for the contributing population since it's targeted or it doesn't mean it's quality targets yeah I just got here talking about alignment what were you doing in alignment between what and who and what so as Ina mentioned each of the payers contracts with the ACO on its own terms they have agreements so there's a Medicare agreement with the ACO department of my health access has an agreement with the ACO for the Medicaid program Blue Cross Blue Shield has a program for their qualified health plan lives so those agreements are expected to align with each other with the Medicare program in particular okay so provided would be paid roughly the same for providing the service no matter who the payer was so for the agreement we're talking about payment mechanisms, services quality measures, payment amounts is not one of those okay now that you've pointed that out there is some reporting around any differentials in the agreement which we're going to start working through soon here but we're just talking about the mechanisms on which we're going to start so this next slide tries to say on one slide what the agreement and care board is responsible for in terms of the model so the certified chemical care organization is responsible for reviewing, modifying improving ACO budgets we actually set the financial target to the ACO in the Medicare program subject to CMS's approval we have that authority in the all payer model agreement under statute we advise Department of Health access on the Medicare ACO rates that basically medicate financial target for the ACO we have the flexibility to negotiate changes to the Medicare ACO program to increase alignment with other programs so we wanted to make a change for example to attribution methodologies to align more closely with how Diva does attribution in the Medicaid program for example after CMS we are responsible for tracking to CMS on the cost, quality and scale performance so how are we doing on those measures as well as how the programs align with one another and then we are trying to have a number of other regulatory processes which you probably heard about that we try to integrate as much as possible in the service of the targets in the opinion so I'll just briefly go over each of those areas first of them being ACO certification it's ACO like licensure and ACO has to be certified by the Green Mountain Care Board in order to receive payments from Medicaid or commercial insurance under the all payer model or any other payment performed program for an issue there are 16 statutory requirements the board has to ensure being met, doesn't want to list them all obviously but they relate to things like ACO governance the ability of the ACO to assume risk, the ACO as a model of care, the ACO's quality improvement efforts and programs patient protections provider payments and the use of health information technology in terms of process there's an initial application that an ACO submits to be certified and then initial certification there's an annual basically review that happens to make sure the ACO is continuing to be all those requirements the ACO budget process is also an annual process there are a number of statutory criteria the board has to consider here in addition to the requirements of the all payer model the board's review of ACO budgets is significantly broader than it is in the hospital context for example the board looks at you know the ACO's financial targets across payers and how they relate to the financial targets in the agreement as I noted earlier the board actually sets the Medicare target subject to receiving access to approval and advises on the Medicaid market the board also reviews ACO's programs and investments for the upcoming year so for example one care is funding supplemental payments permanent or permanent payments to designated agencies area agencies on aging and still nursing facilities under its complex care coordination program basically paying those providers for coordinating care better for people who are higher risk so that's obviously part of spending the ACO level that's reviewed during the ACO budget process things like that the board also looks at the ACO's administrative expenses and how it's managing the risk that it's taking on which can involve does the ACO need a certain amount of reserves, the insurance how much risk is it to providers things like that the next couple of slides briefly talk about the reporting of the degree mountain care board does to the federal government so on the financial measure to across the care I think the I think the I think the thing to point out here is that there's a significant delay between when services occur when claims are submitted adjudicated and paid when they actually show up in all payer claims database that the board administers and which is the source of this reporting so it's about nine months or more so we're just now finishing our total cost of care analysis for the first quarter of 2018 reporting on on this quarterly to CMS with a final report on where 2018 spending ended up kind of at the end of the third quarter of this year Is that kind of a delay considering the standard of care or standard of practice rather than standard of care? I would say yes the standard is about six months for claims but there's some additional steps that we have to do with the claims that come into the database we have to go to the vendor that helps us aggregate them and go over our stuff for the amount of care it out and good news reports so it sounds like a simple thing figuring out how much care costs but it's a complicated specification we have to do this how do we do this we have to approve by the federal government we're just stressing you're well into year two before you even know what happened in year one and therefore can't make that adjustment in year two because it's already going back and that's a percent of life this is Calvary yes Calvary is now into the second year we just started our second performance here but even though you're doing you're giving this report to CMS can you extrapolate or can you get early meetings towards the future I mean you must have something to send her again to one place yes we so we have built total cost of care and analysis backwards so we know we know we're 2017 into that for example for Medicare it's like I said earlier we are responsible for beating national projections so we know what the national projections are so we know where we end up for Medicare so it's not I mean all hope is not lost because of this delay it does make things challenging for sure but so the next slide is kind of a timeline for reporting on scale and alignment so we will be reporting to CMS on scale and alignment for 2018 midway through this year that said we do have an idea of our scale performance so as you can see we did not hit our scale targets for 2018 we are estimating we are not going to hit them this year either but I think you can see there that we're making significant progress in terms of scale and actually actually is just about right I would do the math in terms of how much we were expected to grow we're growing that much but we started from a base that was too long so the anticipation that we would reach scale would be about what are you going to have to ask for a vision we may be required to come up with an implement corrective action plan on scale that's kind of the trigger there is if we miss for two years so it's looking like we're going to miss for two years but there's a lot of work going on with the ACO we talked about reaching out to payers, getting payers to engage in this, getting more providers in with big strides in terms of getting more providers into the model and that's the way you build scale is more providers more payers this provides backgrounds for questions and then this is the reporting schedule for the quality of the applicants measures these are lying for your claims and clinical data calculated until the end of the report I had mentioned the board's efforts to integrate all the different things that it does to achieve these targets I think the center for Medicare and Medicaid innovation was interested in pursuing this model with Vermont largely because the remattent board has some unique authorities so I tried to set those out here the boxes in green ACO oversight including budget review and certification in the Medicare ACO program design and rates heading those are relatively new authorities that the board has as a result of Act 113 of 2016 and as a result of the Elbeer ACO model agreement and then the boxes in blue hospital budget review health insurance rate review and certificate review about things that the board has done for a number of years now and that were done before the board by other agencies and then the final slide is just trying to show that those regulatory levers the board has operate on different levels so hospital budget review regulates hospital revenues of spending on hospital services across all payers health insurance rate review is obviously related to commercial insurance ACO budget review touches all payers to the extent that payers contracted with the ACO obviously the importance of that lever will grow over time as the ACO increases and then Medicare ACO rate setting when it touches Medicare Medicaid ACO review with the funds when it touches the remattent care board recommendations or any modification to their authority to provide the ongoing oversight questions so just getting back to the scale actually if you can go back to one of those slides I wanted to just clarify for me anyway you've broken out Medicare from all payers so all payers include Medicare or is that all payers except for Medicare okay so the top line is the total population okay then just thinking about where we are versus the targets or where we are versus 100% even who is responsible in the current structure for trying to increase those numbers is it the ACO or ACOs or some other entity I would say under the agreement the state is responsible but I would say primarily the ACO has to tell the story to providers if this is a voluntary model so it's got to make the case to providers and payers that this is worth doing come join with people we can provide that to I would say appropriately so the ACO should be helpful what would be helpful for us to hear so Nina and Michael can you help me think about what your preparation is so from Mr. Chairman from Medicaid I think the helpful perspective that we could begin to talk about today is okay based on the theory and regulatory structure that Nina and Michael Barber have described we can talk about being on the ground and trying to make this work for Vermont and Vermonters at Medicaid and how that is going so far right so Mr. Chairman Michael Costed at the Commissioner in Department of Vermont Health Access and I'm going today by Alicia Cooper good afternoon Alicia Cooper is the director on the reimbursement of the Department of Vermont Health Access and so we're going to both talk about this today and very happy to answer whatever questions you may have so you're sitting next to each other in front of each other thanks and so having had the benefit of listening the last several hours of testimony I just want to start with a few comments that might seem obvious but I hope are helpful number one the stuff is hard it is our great privilege at Medicaid to work on this each and every day but for people that don't spend every day in it it is really difficult stuff so I think we expect this is going to be an ongoing dialogue for as long as health care reform persists here in Vermont two I think it's important to recognize that the ACO is a means not a net it's a tool the true goals and integrated system from emergency rooms from primary care offices through VNAs to nursing homes right we want an integrated system of care that delivers the right care at the right time to the right person now the reason why the all-parent model is special and why we're using the ACO so prominently as a tool in payment delivery system reform is that number one of the lines with Medicare and Medicare is the 800 pound gorilla in healthcare reform getting Medicare to align in a way that makes sense to Vermont and Vermonters is really important and unusual so when I say it I think about the ACO program we would be able to offer the same rules and same payment structures to hospitals and doctors whether somebody holds a Medicaid car or someone holds a Medicare card or someone holds a card from Blue Cross Blue Shield or MVP we're trying to make it align on the back end so in a way that would reduce provider administrative burden and make the incentives more aligned with care unless aligned with why I have to do this for this insurer and that for this insurer and measure quality in a different way for two other insurers that's basically what we mean can we align payment and practice with those in docs and other agencies through the all-parent model the other thing that makes it special all ACO is a collection of healthcare providers and it gives us an opportunity to have those healthcare providers take accountability in real financial responsibility for their patients now every single doctor and nurse I've talked to having done this last five, six years is 100% committed to their patients it's about that it's about can we create incentives in a business model that align with that care and pay people who do better as far as caring for folks and then obviously patients this is a I remember for some people in the room I remember former finance commissioner Jim Reardon they used to say that in the state government long-term planning was Memorial Day this project requires much more patience than that performance year two of six year agreement and so for us even just with the claims tail that Michael Barvin described it's going to take a long time to know what happened and whether we're pleased with the results and the last thing is we're going to try really hard from the state Medicaid agency not to over promise on this one we don't know whether the all-parent model is going to work we think because of the incentives it creates and the alignment with Medicare and the fact that providers are taking on this accountability for our community that it's worth trying and we're going to work real hard and we're going to be transparent but we're not in a position to say that the ACL or the all-parent model is definitely going to work so with all that said we'd like to just describe for you a little bit about what's going on with Medicaid can I have a step back just really broader for a minute because I'm sitting here thinking excuse me how do this is, as I said at the beginning this is the we are implementing this policy as the policy of the state of Vermont based on an agreement with the federal government and yet we in Vermont as elsewhere but we in Vermont change administrations we changed administrations just now the governor is going to give us his budget address on Thursday and two years before that we changed administrations from one political party to another political party in terms of the governor's administration of state did we change policy around the all-parent model when we changed administrations or has there been a flow through consistency of adherence to this contract between Vermont not between a political party but between Vermont and the federal government and I think that's it's an excellent question to say that in the transition from the Schumann administration to the Scott administration and from the Obama administration to the Trump administration which also happened shortly after nothing in the agreement has changed nothing in the programming has really changed the only change that I can proceed from my seat is that people are appropriately skeptical of the program and want to make sure that we're proving that it works and so I feel from the people I report to a real sense of we understand the concept we understand the theory we're satisfied that you're implementing it and we can manage it but we're going to really focus on results from our federal partners I think in Ina's perhaps in a better position to speak to this it's the same thing of the ACO is one federal program there are other federal programs and it's really going to work if the federal government is going to continue its efforts here and so we have to have this sort of patience but a real focus on whether we're getting where we want to go is to keep saying you're trying to determine whether it's going to work what happens if it doesn't work so that is a really good question and that's why I think it's important to remember that the ACO program is a means not an intent if Commissioner Gustafson were here what he would tell you is Diva is the Medicaid agency has three priorities we want to get better every day we want to have a complex community projects which has been a sore spot for the state and we want to make more value-based payments that's what we're here talking today we, like many other health plans across the country want to stop paying fee for service for healthcare which is quantity and start paying for quality and so the ACO program is the biggest of about seven payment reforms that we're presently working on that tries to transition from quantity to quality now let's say if the federal government got out of the ACO business tomorrow and the state of Vermont has no control over that what as my strong sense is that as a Medicaid agency we would be going right out to Vermont's hospitals to say gee, you were willing through the ACO to work hard with us on quality and to get out of fee for service for global hospital budgets is there a way to continue that because we'd be really interested in continuing that now we think this way is superior to that way one because it has Medicare in it and two because the providers are choosing to do it themselves rather than having the state mandate that they do this we think there's more promise and potential for long term success but we'd be still focused on making more value-based payments if the ACO is unsuccessful for some reason tomorrow so all the hospitals in Vermont like ACO didn't like ACOs I would not dare to speak for hospital CEOs and CFOs but I will say that they're voting with their feet for the most part to join the ACO program with the exception of Copley and Grace College you you'd have to talk to them what we want to see and you will see on the slides is progress over time that more providers more hospitals and more Medicaid members are joining the program and so far through the three years in the Medicaid program we are seeing about from four to ten to 13 in the three years in the Medicaid program I have just one question to talk about coordinating public care with your providers is there any strict the care that providers may be giving maybe too much care in one area as well as the other and there's an important difference here between as the video said between ACO and HMO there's nothing about the ACO program that restricts the Medicaid beneficiary's ability to go get someone else and there's also no utilization management which you'll hear about in this committee usually when people talk about what's called prior authorization so an insurance company which Medicaid is a health plan much like other private insurers has provisions where it will say look we just don't authorize that care the ACO does not take that responsibility from us there's no situation where the ACO is denying someone care that's being in the place and insurance just not part of what they do also we measure access and quality to try to make sure that we're not seeing sort of big dips in care as we're moving from fee-for-service to capitated payment models which we'll talk a little bit more about very good question I think those are in different ways touching on some of the same issues I mean one of the underlying concerns that's been expressed by numbers of legislators or members of various stakeholders really what's is there some kind of incentive for the ACO to not provide as much care in order to make the bottom line work to save the money etc that's one of the ongoing and then hospitals too as well all providers once you get into the capitated business is it is there actually an incentive different kind of perverse incentive rather than perverse incentive to just do lots more because it's fee-for-service and you can generate money is there a disincentive to provision of care in order to save the money make it all work and I would urge the community to think of this not as an ACO problem but as a value-based payment problem and as we'll get into in a moment on January 1st of this year we launched a mental health payment reform which has a case rate and one of the things that we worry about is a lack of access to mental health care so what we did in that program is to say okay we're going to guarantee you payment designated agencies for this group of people but the access to your services for these particular services dips below 90% of the previous year we're going to take some money back because we need some mechanism to make sure that you're still serving enough people so in each value-based payment we have to think hard about how do we maintain access and how do we make sure we're not creating incentives to reduce the amount of necessary care that's out there so it's just a value-based payment problem and I think it speaks to the issue of this is not going to be the only first and only time we talk about all-fare model when we are from one care it's not going to be the first and only or the next and only time we hear about from one care but there's really an ongoing responsibility, I believe of the health care committee to stay abreast of the developments in all of these in this health care form to stay alert to concerns that are brought to us from stakeholders or outside parties or patients or whomever in order to stay alert to what our responsibility is in terms of understanding and then overseeing at some level from a policy point of view what's happening You mentioned the mental health care that you started in the value-based payment you have a different set of measurements quality measurements what are the needs and the sense and the value of health care in this current chart? Sure that's a great question and I think it gets to bigger questions about quality metrics across these different types of initiatives for the all-payer model agreement there were a number of quality measures that the state is accountable for meeting and to the extent possible with our ACO contracts the different payers have contracts with ACO we've tried to align the quality measures with those that are in the all-payer model agreement so in the spirit of alignment we looked to the all-payer model agreement to see which measures might make sense for a mental health payment reform project and we found that there were some that made sense and there were some that were less relevant to the provision of mental health care services and so where that was the case we also looked at other measures that the state has been collecting the agency network of providers has been monitoring over the course of the last several years and we tried to draw measures from those sources so that there would be some alignment where appropriate but also measures that were more targeted to the services that were being provided So with that branding that we're really pursuing value-based payments and the ACO program is the biggest but just one of the value-based payment programs we have each of these programs so as I said we have those three big data priorities value-based payments performance and information technology projects and just performing improving the day-to-day performance of our Medicaid agency the all-payer model is part of payment basically our payment reform action Alicia led our payment reform team she's recently taken a role more broadly over our three reimbursement units because we set rates for new payment models value-based payment models are standard fee-for-service rates which still exist and now Diva also oversees nursing home rates and private non-medical institutions so that's Alicia's piece of this so far this afternoon we've really been talking about the all-payer model and that is our contract with CMS to enable ACO fees for reform and so CMS as Michael may have said there's some flexibility and some local control in exchange for meeting quality, financial and scale targets and so our Vermont Medicaid next-generation ACO program is our component of that and it's growing over time and the table here gives you some sense of how it's grown certainly so you can see in the table that in the 2017 performance year which was our first performance year for the Vermont Medicaid next-generation program we had four hospital service areas that were participating that equated to roughly 2,000 providers and we had approximately 29,000 Medicaid beneficiaries who were attributed to the model as Michael noted over the last two years we have seen growth in terms of providers voluntarily choosing to participate in the ACO network it went from four communities from 2017 to 10 communities in 2018 and now 13 communities in 2019 with additional providers agreeing to participate in this model voluntarily we also have more Medicaid beneficiaries who are attributed to the program so in the current performance year we have approximately 79,000 Medicaid beneficiaries who are attributed so to put some context on that as for the purposes of scale we want a model that has all Vermonters so for Medicaid we have people that have full Medicaid benefits packages and then people with other limited benefit packages when we think of scale in the Medicaid program we're just thinking about those full Medicaid beneficiaries so if you're a dual eligible you're eligible for both Medicare and Medicaid you're on the federal rule state that you're on Medicare side of the street for scale so for Medicaid we have about 79,000 out of 140,000 full beneficiaries approximately that number changes all the time but that's the ballpark where we're at for scale so it gives us 55 towards 60% of full Medicaid beneficiaries that are presently in the ACO program now just to tie into what Michael said a little bit we keep thinking of ways to look at scale on one hand this is an issue where we expect the ACO to persuade health care providers that this is a good thing to do and so to the extent we have hospitals that are so far choosing not to be in the program or federally qualified health centers or other folks who have chosen not to be in the program the ACO is going to have to do the hard work of convincing them to get in at the same time the federal government has a bunch of complex rules about how to count people and to be quite frank some of them don't make any sense and so getting those people inside the program would be especially difficult and so Diva is working on is going to pilot this year some what we call alternative attribution models to see if we can get people counted in a different way and our all pair model agreement allows us to oppose to the federal government alternative ways to count people so you know scale is a big picture thing and then we think how do we solve the problem the ACO is going to have to make sure people want to be in its network and then we need to work on those federal rules for how to count people because not all of them are tailored well to the state of Vermont I have to say I don't understand we have 13 of how many hospital service areas 14 so we have 13 or 14 hospital service areas I remember Dartmouth is included though in a number of hospitals okay but if I just say Cochle and I just like said no so I don't know Dartmouth gets out of that so those hospitals are participating for Medicaid but that doesn't mean all the providers in their hospital service area are participating and attribution is tied to primary care so for example a couple years ago one of the big milestones we saw this year and where we really pushed the ACO was participation of federally qualified health centers so you can have UVM in and Chittenden County but if you don't have community health centers Burlington where lots of people get their primary care it doesn't make as big a difference as you would think and so this year we're seeing a migration of some FQHCs into the program and that makes a difference and so we're trying to tease out over 60,000 people how much is missing primary care folks and then how much is just technical problems with attribution due to federal policy and that's one of our big goals in 2019 so just by chance I think I understand correct me but that the community the FQHC for Chittenden County is going to participate starting in 2019 and they're going to participate for Medicare and Medicaid but not for commercial is that when I or something close to that okay so we're all hearing it but someone's going to communicate with somebody officially so I assume that somebody's talking to somebody at Diva well yeah I mean so we um this is where it's interesting actually you're not talking to Diva you're talking to one care and one care case with CHCB there are moments where we have our payer had on as Medicaid and moments where we have our Vermont healthcare system had on when it comes to joining the ACO we try to keep our Medicaid had on we want to leave those discussions between the ACO and providers so we would not normally kind of get involved in discussions with a provider whether they want to join the ACO for Medicare and those relate to what Michael was talking about in terms of scale getting up to scale those decisions are what's influencing those percentages of getting up to scale and they're made at the logo level by the provider in their relationship to in this case one care as the ACO the ACO is part of the all payer volunteer Henry you're a provider and you want to join the ACO you can decide you just want Medicaid and Medicare but not commercial insurance as I work with the old payer so my understanding which one care can talk more about is that they basically offer them as separate opportunities you can join for one, two or three payers and I what's been told to us by folks in one care and the provider community is people want to dip their toe in the water this is a big change and they want to be really careful and responsible about their business so what we've seen is providers tend to join Medicaid first to get an understanding of how it will work with their business both in changing how people get paid and how they care for people and then if that is successful or comfortable then they think about expanding other payers so I think Medicaid started a year earlier we started in 2017 with this ACO with the next generation ACO program and so you're seeing more folks I think go through Medicaid first to get a sense of how it works and then add on additional payer programs over time but isn't that either more expensive or more complicated with providers then we have different billing systems for you know they'll have perhaps I would also say potentially less risk involved right if you're not changing more than one payer at a time but you know I think my discussions with hospital leadership over the last couple years in the hospital association is that it's a really individual decision for each hospital it's a really individual decision for each primary care practice about whether they want to take this on so I don't want to speculate more than I want to about their decision making on this. My observation seems to be that more folks are joining over time and providers tend to start with Medicaid and then move into other programs So I'm going to remind myself and us that what I'm really one of our goal here today and our goal over the past week and our goal here today is to get to try to get a basic foundational understanding of how this all-payer model agreement is working for Vermont so that we can have more policy discussions and look more in depth about is it working? Should it be working differently? And so we're kind of I hear myself asking questions at times which kind of let's understand it as best we can knowing that we're going to come back to asking whether we think it's a hard question, a tough question or a policy question about should we be doing XYZ so let's I'm just going to remind myself to try to achieve all of that in one afternoon is way beyond what makes sense. Can we do this for another four or five weeks? And I thought Brian because we're having so much fun I thought maybe we could continue this for five more hours. Way to drive people off the we won't be doing that but I do want to just acknowledge there's a lot we're taking a lot of information and the questions that you're asking are actually really on point questions and we'll be coming back to a line as we deal with policy questions so we talked about creating and integrating that the ACO is a means on end and the end is an integrated system of care and so part of what DEO has been trying to do is figure out okay that's a nice talking point what does that really mean and so what we've been trying to do is pair ACO based reform with what's traditionally being called a Medicaid pathway which is a fancy way for saying how do you integrate Medicaid payment into every system reform across the whole care continuum because when we set up the all-payer model it's based on Medicare A and B services as Enan and Michael said and that's a lot of what Medicare pays for it's like almost everything is set for prescription drugs it is a lot of what commercial insurers pay for but it's only about 35 maybe 40% tops of what Medicaid pays for because Medicaid pays for lots of things that other healthcare payers do not pay for and so we have a particular challenge of Medicaid of asking what is value what do value based payments mean in all these services that we partner with DMH and Dale and DCF on and so beside just the ACO program we've been looking at other pieces of the care delivery system and then most importantly listening to our sister departments to say where are the opportunities to do other value based payments and how do they align with the APM and so something we want to talk to this committee about more obviously not fully today is that we put out a Medicaid pathways report this year that we're particularly proud of and it proceeds in two sections it talks about payment reform as a process we want policy makers to understand it not as a talking point but as a process a thing that people do every single day and then to talk about the actual projects that are ongoing in it which the ACO is the biggest but it's not the only so I would encourage folks to review the report if you haven't had the opportunity already I think it's a nice summary as Michael said of the process that we've been trying to make a little bit more standardized as we approach these different value based projects within Medicaid the broad overview of the process is that we as part of the payment reform unit at Diva have been working closely with the other departments within the agency of human services on four steps that we like to go through to get us from an idea to hopefully a new model that we can meaningfully evaluate the first of those steps involves planning we do some work with whichever department is requesting to engage in this process to identify what the challenges there are that they can see and what problems they would like to solve and then we think about whether or not payment reform is the right way to address those problems this part of the process involves gathering subject matter experts and other stakeholders who can inform the process throughout it also involves quite a bit of research to understand how for example other state Medicaid programs might be dealing with similar challenges and problems solving I can't even just say so now what you're describing now is stepping away from the all pair model agreement, ACO agreement to talk about how to do a parallel payment reform value based payment reform with other parts of the agency of human services payments that are not necessarily a part of the all pair model this is a way of yes what I would say is we're stepping towards okay so we had let's think about it chronologically we had a negotiation with the federal government in 2014 through 2015 and 2016 for the all pair model while that is happening Diva and Medicaid started the process of saying how would that really work how would you actually go about the generation of ACO programs and so we've developed this payment reform process so it's the process that was used for the ACO program and is continually being refined but yes it pulls us out of that like all pair model total cost of care in service of value based payments across the whole care continuum we look at like the umbrella being not the all pair model but being value based payments so you're right we're going a little away from the all pair model agreement but in service of delivery not its promise of a full continuum of care but specifically for payments that you're currently making that wouldn't be encompassed under the all pair model yeah it was okay that's what I was trying to get that these are other Medicaid payments or not just Medicaid but they would be Medicaid payment because that's your work other Medicaid payments that aren't encompassed under the all pair model but where you would like to achieve the same kind of value based payment reform if possible yes and there are provisions you're entirely on it and I would say yes and the way it specifically ties into the all pair model is part of the all pair ACO model agreement there are planning requirements to align other pieces of the care continuum with the ACM over time sort of in contemplation of an extension of that agreement starting in 2023 so what might be helpful for me can you name areas that you are well aware of it's likely to happen across the agency of human services the first is certainly the Vermont Medicaid next generation ACO program as Michael mentioned that's kind of our flagship payment reform model because it was most directly connected to the all pair model agreement but from there we have worked with the department of Vermont health access and other departments within the agency to begin work on several more projects including a project related to applied behavior analysis a project for children certainly it's a set of services for children with autism spectrum disorder diagnoses we're trying to see if there is for that project in particular a way that we can make what is currently perceived as a challenging fee for service billing arrangement a bit more flexible for providers so that they can have the ability to deliver the right amount of care when they're interacting with the child we're working with the department of mental health on children's and adult mental health payment reform as Michael mentioned that launched at the beginning of this calendar year we're working with ADAP on a residential substance disorder treatment payment model that yes thank you very much we're working with the department of disabilities aging and independent living or Dale on a developmental disability service payment reform project and we're working with the department of health children with special health needs unit on a pediatric palliative care payment reform project going back to developmental disability services will that be including Alzheimer's or dementia patients is there any will there be something there for them I want to go back and look at we're sort of at the beginning we're in the middle of this one and I just don't want to speak about pricing what was in our model I know that Brian has a particular interest in Alzheimer's issues so no you showed up with me so understanding where that fits or doesn't fit into some of this will be a particular interest and it may not fit within certain categories but then the question is where does it where does it fall and what I really appreciated about these payment reforms particularly the mental health and the reform that just launched and the development of disability services one that is a big mountain to climb and we'd love to launch on January 1st in 2020 there's an idea of an ACO based reform that it's really hospital centric and I get that because of the payment model but we're trying really hard at DEVA to go to our sister departments and VHS and say look, we know that you have good ideas about how to change payment we have people that specialize in how we think about value based payment models let's work together and so these ideas are really bubbled up from the departments themselves it's been great to be their technical advisors to really support them on this and so we're grateful for that excited to see what happens with these seven projects or six projects and keep inventing a lot of these projects these reform projects do you have the money for them is it part of your budget projective budget so one of our guiding principles representative page is to pay the reform projects ought to be relatively neutral this is about how we pay not what level we ought to pay both of us we don't have the additional money in our budget and frankly we really value stakeholder input if it becomes just about whether I'm paid enough we will never get off her space to have a discussion about how to really increment payment delivery system so we acknowledge that attention but we all sort of mutually agree that we're not that this is not the space to have that discussion this is the place to lobby for a more flexible way of providing the service that's already being that's exactly right and I'm told there are various buildings in Montpelier that's appropriate to lobby for additional funds there are different points of view about that we'll find out Thursday I guess but that's an excellent point because the conversations generally start with more and then we say what if there are plenty of problems to solve but some of them are really basic that it's basic conceptually but really hard to focus on the ground so on children's and adult mental health we have a situation where DMH and Department of Mental Health are paying for the exact same thing in different ways for a different amount of money that does not make any sense for Vermont and Vermonters and so part of the project is just trying to unwind things like that and to make it so if someone's house is on fire a DA isn't saying well do I use the DMH hose or the DEVA hose just use the hose and so we try really hard to prioritize how does common sense fix this in these payment reforms so I'm remembering this from many many years ago now but there was an attempt to try to bring services for children and families into the community and do family intervention or family I'm not saying about to go out into the community to intervene on behalf of certain adolescents and families and I remember in the agency where I was the director they were like tied in knots because Medicaid or Medicaid primarily would only reimburse for a psychotherapy session that was had one on one with somebody but that's not what was really going to be the most useful intervention for that adolescent or that family maybe it would be sitting down with the teachers at the school and there was a it's basically with a payment reform effort to try to say isn't there some way to change the way even if it's just the same amount of money to change the way we can get reimbursed so that we're not having to try to do what we know what actually makes sense doesn't fit with the payment scheme that we're strapped with which is a psychotherapy in an office we would scheme it took a long time but it was successful and that's really the basis of the bargain here and we're trying the ECO program for the most refined so far to say okay providers we give you more flexibility and we guarantee you some level of payment can you do it better because we know there are all sorts of ways in which it presently doesn't make sense so those are the six that we have we also have nothing worse than using the internet in front of people this document which you had before you was also just sort of a more detailed summary of the payment reform projects and so we if the chair would like we can walk through each of these now or at some point later it's a deeper dive on those six projects some point later and then certainly back to the ECO program I think we have again tried to be really modest about the results of that program I know just to tie a few loose ends from before we've gone through one 2017 was the first program year that's been completed it took us until the late summer of 2018 to figure out exactly what had happened in 2017 so there is a lag time to that so it's probably going to be sometime in the spring or summer of this year that we'll figure out what happened in 2018 that's due in part to the claims lag it just takes several months for us to know everything that happened but in general we can say a couple of things about the ECO program one it is growing as you saw in that chart we're seeing more providers and Medicaid members in there number two where so far expenses are coming in right around the target which is a good thing we set a price for services for the ECO for the year and then we provide basically monthly payments for part of it and then some fee for service payments come in as well because we never limit where people can go for services so far we're seeing a little more we think utilization of primary care for people inside the model rather than outside the model we want to be really careful with that we're seeing people inside the ECO we think so far in the first year seeing people inside the ECO use the primary care doctor a little bit more than people who are not with the ECO program that's something we're clearly going to keep an eye out on and then we're able we think to administer the program which is not a big deal we started in 2017 we could actually pay in a different way and measure we done all sorts of readiness reviews and checks but we think basically we can do it and then the ECO hit about 85% of their quality measures in the first year and we're going to keep an eye on that I think it's important though to realize that we're deliberately at EVA being really incremental about this we started off saying okay about 1.5% of the money that we pay you you have to meet quality measures to get to earn that it's now about it's now about 2% it started at 0.5% now it's up to 2% we have risk which is just a fancy way of saying if they overspend they owe us some money and if they underspend they get to keep it at a certain level and then to 4% so we're really looking just to make incremental progress on the ECO program and we're happy to come back and talk more about that completed program year as well because it deserves its own attention Ruchin Care Center outside of emergency rooms where are you even looking at that or dealing with that so I know that the legislature directed us to study pre-standard health clinics so I mean it back to us can speak more about that for us I actually asked our provider member relations folks last week whether we're seeing any of that we've enrolled in Medicaid urging care clinics that are affiliated with hospitals but I don't believe we've enrolled like minute clinics or free choice MD or any of that you know we as a Medicaid agency haven't talked a lot about that and so we haven't taken any sort of position we can't help but look across the country and see a lot of it so and I think that the freestanding health facility work group concentrated a little bit on that and then a lot on the ambulatory surgical center that's been discussed the last few years so we keep an eye on that but I don't think we have a refined position as a Medicaid agency it's going to be possible to send us a link to them of course we do it helps that Mr. Chairman we can send a little report we did on the results of the 2017 state program I'll send it to Demis and then she can copy it to members and also close to them happy to send both of those this may be a later question so you can just find out when you're getting more and more hospitals before the 13 do the results of the quality metrics take into account the different maybe some areas of the state have more health needs than others and when you review the quality metrics is that taken into account so I'm going to defer the question of quality to Abisha I would just say that on the front end when we set the price for the ACO that's based on the claims history of all those people so to the extent we used to have Chittenden County and now we have Chittenden County and the Northeast Kingdom to the extent health care is used more or more costly there that will show up in how we set the price for those folks but I would defer to Abisha because we are only looking at performance for the full ACO network so your point is right the network looked a little bit different when it was smaller and only four communities than it does this year when it's 13 communities but the results of the quality measures will be calculated by pooling performance from the whole network of participating providers so it might look a little bit different but to Michael's point the connection between quality performance and the financial aspect of the program relates to how we're setting the rates based on which individuals and communities are actually in I would add one more thing that's sort of in the spirit of your question but not directly there is we ask ourselves Medicaid in our program what is the role of local variation or local innovation in the all pair model we have instituted some provisions in our 2019 contract that talk about some pilot projects in St. Johnsbury that start to get at that question of well this community wants to both be in the ACO and do something different what does that mean and so we're going to spend 2019 working on them on various projects to try to see how much local variation and innovation can happen underneath this all pair another little follow up question some the metrics you're finding out that they're using more primary care set in some places than others which you said and it is there a do you have any I know the quality metrics are basically numbers is there a narrative as to why people would be using primary care I mean would we know why or would we just know that they're using more I think we don't know why quite yet like Michael said it was one of the interesting indicators that we saw when we were looking at utilization patterns in the first year of the program what we're hoping to do as the program the chores is start to understand some of the reasons behind why there might be differences if those differences persist I think that's one thing that we'll certainly want to know once we look at the 2018 performance is it the same or is it a completely different pattern if it's the same several years in a row then we know we'll have some sort of signal that we can be working with one care to understand it better I think one thing we did not fully appreciate before we started the program was how difficult it is to assess what's really happening when you're not fully at scale that was the other question how can you account for that you've gone from 4 to 13 is it deferred maintenance that people are using final care more there's a whole bunch of things first of all having base years of experience that were right around the time that ECA was rolled out makes it hard to figure out historically what was going on but then other than that we've gone from 29 to 42 to 79 but they're not the same people so now we do things like what we call the staters, levers and joiners analysis oh man trying to figure out who's actually there we're really interested in those people that had ACO were inside the ACO for multiple years want to see what's different what's happening but the sort of vagaries of attribution how you account people and the fact that with Medicaid there's a bunch of churn going in and out all the time makes it hard because it's another sort of tension that I think when we started this program we set out that we didn't truly understand it our goal is really to have a predictable, sustainable Medicaid program for taxpayers and for Vermonters and for providers in Vermont but Medicaid's not that stable there's a small group of people that are on it and then there are lots of people talking to the ACO about what does that mean how should we think about those people if the average length of stay for a Medicaid beneficiary is 14 months in the program how should you think about sustainable multi-year transformation and these are a couple years ago we weren't sufficiently in the onion to fully appreciate these questions but now we're really taking the data and trying to figure out what the real story is and how best to modify the program but that right there not being totally at scale and having it not be the same people every year makes it really challenging to figure out what's going on without overstating the case about what you know I'm going to wait until a future time that's fine other questions at this point I think we'll stop there thank you Michael thank you Alicia and Ena and Michael we have a lot of information put on the table here today and committee members thank you for your questions that's really useful to see where questions emerge from and I think they are