 Good morning, welcome everyone who has chosen to visit us this morning. There are, as everyone can see, a lot going on. We have a lot going on. This crossover from the policy committee last Friday is right now, though. Ways and means, preparations in CAF and the students' committee are all dealing with their crossover. So some of our committee members are necessarily involved in those committees to try to work on some of the pieces. So there may be some members who are not in the room for a follow-up this morning or maybe any of us this morning, because they've been deputized for other tasks. It's not an indication of lack of interest on their part. So what I want to do, what we've decided to do this morning is to try to give our committee both some background and an update on the whole payer model, which is an important piece of health care reform, health care changes in Vermont. And some of this will be familiar to numbers of you, and for others it will maybe be the first time that it's really been laid out in how did we get from where we were to where we are now. And I think it's important for all of us to understand that. And then we'll also have an opportunity to get some update from the green amount of care board about their work in the health care model, as well as people. What I'd like to do is to invite Nina Backes to join us first as the director of health care reform for the agency doing the services. And of course, Nina brings a great deal of background experience with the health care model over the past couple of years and she can share some of that with us as well. So, good morning, Nina. Welcome. So let me just say, if I may, that I think I'd like to hear from give Nina the chance to give us some information. And then I'd like to appeal to Susan Barron to sit there and have the green amount of care board follow up and to Alicia. And we're going to try to do this between now and 11. I'd like to do that. But I'm also, I think what would be useful is to have give Nina the chance to present and then have them take some questions and then have Susan present and then take some questions and then do the same. So if committee members disagree that we can hold questions between each presenter, I think that would be useful but we'll manage it. If there's questions that really need to be asked in order to understand what's happening, we'll indicate that and we'll all work together to make sure things get understood. So with that, Nina, I'd like to turn it over to you. Thank you. Good morning. My name is Nina Bacchus. I am the director of health care reform in the agency of human services. Thank you for asking for us to provide or for me to provide this history in context today about the all-payer accountable care organization model agreement. I understand that the committee wanted to look at the background and the lead up to the agreement that we now have with the federal government. It's important to start with what Vermont's payment and delivery system reform goals are. We have a primary goal and a cost containment objective to move away from fee-for-service reimbursement to a population-based payment model or a global budget model. And very wise people would describe this differently than I would as someone who is steeped in the day-to-day vernacular, if you will, of health policy speak. Other people would say, this is like paying our current system fee-for-service, which is the predominant reimbursement model, is like paying for time and materials versus if you're trying to build a house paying for getting a bid for the total project and having that budget set up front. That's a way to look at the difference between fee-for-service paying for each and every service that's delivered in the health care system versus paying for what you think is the best estimate of the costs that the providers need to deliver health care services in a flexible, high-quality way. That being said, we are looking to employ a reimbursement model that directs payments for quality and outcomes, whereas a fee-for-service model may pay for what would be characterized as wasteful health care spending or duplicative health care spending. A reimbursement model that provides for a budget and is linked to health and quality outcomes then requires that the health care system is performing at its best and that the services being delivered are delivering better outcomes for monitors. Can I pose a question that I should have posed earlier for you? But what is it that brought this to Vermont's attention as this is an initiative we should engage with? I'm just going to, in the broad sense, and everyone recognizes there's often reference but there was a time when we were going to look at universal publicly-financed health care and then that was really moved forward for a period of years as the intent of the hope and the plan and then that was determined to not be feasible to move forward with and then in some period, something in the intro after that stopped. And then I think some people were like, and now we're doing all-payer model and how do we get from one to the other? Is that anything you can help us with? I can help with that. I think that transition is a piece of what's confounding for some people. I think it's a transition, it appears as a transition but is not, in fact, a transition. It was a concurrent effort on behalf of the legislature and the state of Vermont recognizing that how you pay for health care and how you collect the money are two different things. The work to provide for a universal publicly-funded health care system is about how you collect that money. The work of the all-payer model is about how you pay for health care, meaning you pay for services in a fixed perspective payment rather than for each and every service as it is delivered. And that's a key distinction when the legislature enacted Act 48 in 2011 and we'll talk about that as we work through the history and context. It recognized that the health care spending in the system was not sustainable and that spending and the way to get that spending under control was to look at how we could pay differently. The notion of collecting the money and providing for a universal health care system of some kind was not in isolation from the need and the recognition that there had to be key cost containment initiatives so that the state could afford, if we were to arrive at it, that universal publicly-funded system. So there were simultaneous initiatives given that I was in judiciary at the time, to be honest, I wasn't chairing this committee. I think maybe in the public view the universal publicly-funded system kind of took all the attention or a great deal of attention and I think there may have been less awareness that there was a simultaneous piece of looking. I mean, we certainly were hearing about the need to contain costs and that there was some level of initiative that was already underway at that time and then this has, what we're talking about today is the continuation of that initiative even in the absence of the decision or even having made the decision that we were not going to pursue the publicly-funded universal care at the time. Act 48 set those two pieces in motion at the same time. That's important to understand. Yes. In Vermont's goals for payment and delivery system reform, we also appreciate that we need to create incentives to coordinate services across the care continuum and to improve care and well-being for Vermont troops and fee-for-service, not only does it and can it induce unnecessary utilization, it also creates a fragmented healthcare delivery system because there aren't incentives in the reimbursement model for providers to coordinate with each other. If they don't coordinate with each other and persons need more services, they're paid for those services. There's also not necessarily time in the reimbursement model. The reimbursement model is reimbursing providers for every service that they are billing. There's no code that you can bill for calling another provider on the phone and coordinating care. Collaboration or coordination. That's right. So those are the key objectives and part of Vermont's payment and delivery system reform goals. And to achieve those goals, we have arrived at the all-payer accountable care organization model agreement as a way to see and we have this agreement with the federal government. It's a five-year agreement. We are through the agreement. We will continue to shift from reimbursement to prospective payment and to see if that allows us to achieve our goals. At a very high level, what that looks like is, in the state of Vermont, there's an accountable care organization, One Care of Vermont, which if you've heard from already, you should hear from again. Well, we're going to hear. This has given me the opportunity to say so to be clear that we've invited One Care to be presenting to this committee next, early next week. I think early next week. And so we wanted to have this presentation first so that there was a broader understanding and we're going to be hearing from One Care much more specifically in the early next week. So I will leave it at a high level that One Care of Vermont is an accountable care organization and the federal government recognizes accountable care organizations as groups of providers an integrated network of provider that the federal government is willing to provide for an alternative payment. Medicare will pay an accountable care organization in a prospective way. And in Vermont, we have a single accountable care organization and at this time, the accountable care organization model agreement expects and this is what is happening for there to be consistent contracts between the major participating payer groups that's Medicare, Medicaid, and commercial payers and the accountable care organization and the agreement expects that those contracts shift risk to the accountable care organization by providing a alternative payment. So One Care of Vermont, the accountable care organization in our state is receiving alternative payments from these three groups of participating payer types. Is it this agreement that actually allows that to happen? It allows that to happen for Medicare. I mean that's a key piece. Yes, yes. Part of the agreement is premised on the notion that for providers to change how they're delivering care the incentives need to be as aligned as possible and the agreement asks and Susan Barrett and others from the Greenback Care Board can talk about this more. The agreement asks that the state is looking to see how the payment models are aligning in these major payer contracts. Does that include for the sake of coordinated care and so forth working towards alignment of things like pre-authorization so that doctors are not like having to look at which insurance or even a description at one time that part of the concept was a patient coming in to a doctor from the provider's point of view it was payer agnostic. The provider wouldn't have to sort out who's your payer and what does that mean and that that was what was really fundamental to being able to have that coordination of care. To what degree is that part of it? That is certainly something and I'll let the Greenback Care Board speak to how it analyzes and provides for its assessment of alignment across payers but that's certainly an area that I think it would be assessing to see what that looks like in terms of the participating payers. So it is part of the goals of how it would function ultimately. Yes. I don't know if we skipped over this but maybe you're going to come back to it in terms of who the agreement who are the parties to the agreement with the federal government. Does that... The state of Vermont has an agreement with the federal government and that agreement provides for many, many, many things but the important part in what we're talking about here is that that agreement provides for the Greenback Care Board the Medicare rate of growth for the ACO. So it provides for some while Medicare is paying ACOs in this alternative way through its own programs the Medicare program in Vermont is customized and the state of Vermont has a lever there in establishing the rate of growth for the Medicare program. The agreement provides for many other things in addition and I will touch the wave tops of those things and the Greenback Care Board will go more to death. So what does the all-payer ACO agreement provide for Vermont? In addition to the flexibility that we have as the state in how we provide an alternative payment model and guide that for Medicare we have in turn have to achieve reasonable rates of growth and those rates of growth have to be rates of growth that are amenable for the Medicare program and then also rates of growth that we as a state think are appropriate for the health care system as this is a cost containment effort. So we negotiated a lot with the federal government about what those reasonable rates would be. So we have reasonable targets across all payers for limiting health care cost growth and those targets are assumed that they can be met because of the alternative payment model that this agreement sets up. And this is the agreement between the state and the federal government. Medicare has a participation agreement that is separate with the ACO and that's where the actual when you hear the term all-payer waiver that's where the actual waivers are flowing between Medicare directly and the accountable care organization and then the accountable care organization also has contracts with Medicaid and commercial payers. But the agreement between the state and the federal government creates reasonable targets for limiting health care cost growth and that's for Vermont residents. It creates meaningful measures and targets to support population health improvement. The Green Mountain Care Board will go over with you what those targets are and how they're measuring. Protection of Medicare beneficiaries meaning that Medicare beneficiaries in this model maintain all of the same protections that they would have in a fee-for-service model. Nothing changes whatsoever for Medicare beneficiaries. There are enhanced benefits for Medicare beneficiaries. There is the access to some additional benefits for those who are attributed to ACOs but no benefits are disrupted in any way. This model and our agreement with the federal government allows us to preserve some successful Vermont health care reform programs. Specifically this model allows for funding to remain in the state of Vermont Medicare dollars to support the blueprint for health and the SASH program. Prior to this model the blueprint and the SASH program were being funded through Medicare by the advanced primary care practice demonstration. That was a Medicare demonstration program that Medicare sunset finished and we're no longer going to be providing funding from Medicare for those types of programs. We negotiated with the federal government for funding for those programs to remain in our base, so to speak so that we could continue to fund them. Just as an aside for the committee as well on the list of presentations that we haven't had yet is from the blueprint for health. We're trying to simultaneously deal with a number of policy issues and laying to help the foundation for all the different significant initiatives. The blueprint is one of the pieces that we will want to have a presentation about in more depth initially. Certainly, yes. What do you do? I'm just not knowing. I'm trying to see how the balance of this is there's a lot here. We can go, I'm flexible however don't mind if you want to interject but I'll let you try. I'm trying to I think I talked about the Vermont specific local control in this model meaning that the Green Mountain Care Board is setting the benchmark spending that's the per member per month spending for the Medicare beneficiaries that are attributed to the accountable care organization and it's also setting the rate of growth for that spending. So each performance year of the model the Green Mountain Care Board sets the rate of growth how fast Medicare will grow and that is very specifically local control. Medicare has a program of alternative payment models for accountable care organizations. Medicare sets the benchmark and the rate of growth. It doesn't for those programs they have no there's no state control of that in the rest of the Medicare program. This is also provider led reform meaning that there's flexibility of dollars the dollars are flowing in a different way. The accountable care organization is a network of providers and that network of providers is working together to determine how to work in this new payment model to deliver health care services differently and to improve the well-being of the launchers. In addition to that as we negotiated this agreement we simultaneously had stakeholder conversations with health care providers in Vermont about how we would operate in this alternative payment model. So provider led reform means those two things at once and what we heard from consistently during those stakeholder conversations and as we go through the timeline you'll see how long we were how long ago it was we were having those conversations and that we continue to we heard from providers that it was very difficult to approach payment reform with with their foot in two different venues meaning that if they were in a payment reform project where the payment was only changing from one payer or from part of their patient panel then it was an expensive and difficult proposition to think about changing care delivery for some but not all and that's a really important part of why we have scale targets in this model to include preponderance of Vermont residents and also why the model looks to be consistent across all major payer groups that was something we heard from providers very early on when we were working through the and I say we when I was at the GreenMap Care Board we were working through the charge of Act 48 to develop payment reform pilot projects that was something we heard from providers this model includes a six year phased in approach to implementation we're now in the first quarter of performance year two it was very important for us to have a lead in time because of the significant changes that would require so in 2017 was actually performance year zero meaning that we were preparing and the providers were preparing men for payment change the state and the federal government have an agreement that there are no financial penalties to the state or providers if the targets in the agreement aren't realized it doesn't mean we'll be successful if we want to continue in an agreement if we don't perform under the agreement the appetite to have a next agreement might be might be curtailed and there is a substantial accountability for this model via the oversight of the GreenMap Care Board and that is both through the agreement itself and everything that is prescribed in the agreement in terms of what the GreenMap Care Board needs to monitor and report on and it's also through the legislature in 2013 where it requires the GreenMap Care Board to review the budgets and to certify accountable care organizations operating in Vermont. So that is where we are today how did we get here? The background, like I said we spent quite a bit of time negotiating with the Center for Medicare and Medicaid Innovation the Center for Medicare and Medicaid Innovation was created by the Affordable Care Act created specifically to test alternative payment models for the federal government. I say that because it's very important for us to see that while Vermont is we're very much leading in this area but the federal government is also pushing in a variety of ways it's pushing towards what it calls value-based payments it's pushing states to pay in their health care systems for quality and outcomes rather than fee-for-service. In 2016, like I just mentioned the legislature it granted authority to enter into the all-pay-or-model agreement if we were consistent and with the principles outlined in Act 48 and also that is where the requirement for ACO certification and budget review was created for the Green Medical Care Board to engage in those activities and in 2016 the governor the secretary of the agency of human services and the chair of the Green Medical Care Board all signed the all-pay-or-accountable care organization model agreement with the federal government in October of 2016 Stepping back even further as I said the Affordable Care Act created the center for Medicare and Medicaid innovation it looked at how states could test innovative payment and service delivery models to reduce program expenditures and it specifically named accountable care organizations as one of those models I talked about this already to a degree Act 48 created the Green Mountain Care Board and empowered it to look at alternative payment and delivery models for controlling the rate of healthcare costs so we've gone over this a little bit as some of the context for how we arrived at the agreement that we have today in 2013 the federal government awarded states with state innovation model grant funding and Vermont was one of the first cohorts of states that was awarded this funding and this funding was specifically for testing alternative payment models with an emphasis on multi-payer payment reforms in 2013 the Green Mountain Care Board created a multi-payer accountable care organization shared savings program the shared savings program was Medicare's first ACO program where providers would be held accountable for quality and performance in the healthcare system but where the savings if there were savings would be shared between payer and provider and the risk was not shifting from this called one-sided risk the risk was not shifting from payers to providers I think it's really important that when this opportunity arrived for Vermont and we had the funding of the SIM grant that Vermont felt that it was important to test this model the shared savings model on a multi-payer all-payer basis so the Medicare program had the model that it was running Vermont participated in that and then Vermont provider and state stakeholder process arrived at a Medicaid and a commercial program so that was a first that was our first multi-payer effort the shared savings program very importantly didn't change the fee for underlying fee-for-service reimbursement model it did not provide for upfront dollars for healthcare providers to use it in a more flexible way it did not shift the risk for that spending on to providers in 2015 the federal government developed the next generation ACO program so it looked at what was happening with the shared savings program and it wanted to develop a way to shift more risk it provided for a payment model that offered monthly per beneficiary per month ACOs and it permitted ACOs to accept higher levels of financial risk also in 2015 congress enacted the Medicare access and children's health insurance program reauthorization act known as MACRA this is a piece of bipartisan legislation it repealed the flawed sustainable growth rate for Medicare it said okay we tried to contain Medicare costs through the sustainable growth rate formula it hasn't worked we're going to repeal it and the focus of MACRA was to look at that Medicare cost growth and to seek to contain it through value based payment models MACRA is very clear in moving Medicare towards paying for value for outcomes and quality in 2015 the legislature enacted Act 54 which allowed for the state to pursue an all-payer model in 2016 the Greenback Care Board and the administration presented a term sheet for the all-pair model proposal to the federal government to the legislature and that term sheet detailed all of what Vermont wanted to see in the agreement I will say that after after we had a draft agreement we crosswalked the term sheet with the draft agreement and there were some key areas where Vermont's proposal to the federal government had changed based on our negotiations and that was a very interesting way to capture how much our negotiations with the federal government influenced what had been our initial proposal and largely some things that came into that I think are really good parts of the agreement in terms of ensuring that Medicaid beneficiaries maintain all of their access to services and that there is an effort to understand what the differential is in payment between Medicaid as a payer and other payers participating in this all-pair model like I said Act 113 was also passed in 2016 I think responsive to the information that the legislature was hearing about this all-pair model agreement and as I said it provided for substantial oversight responsibilities for the Greenback care board and again in 2016 we signed the agreement and here I list what the agreement provides for which I've largely explained to you in the previous slide but there it's detailed as I said 2017 represented year zero our agreement not a performance year for which Vermont was being Vermont's progress was being tracked with our federal partners however in 2017 the department of Vermont Health Access signed the payment model contract with one care Vermont so Medicaid launched its program a year prior to the launch of the all-pair contract and Alicia will be here to talk to you in detail about that Medicaid program and in 2017 the Greenback care board anticipating the start of performance year one which was 2018 successfully completed the process of evaluating one care Vermont's budget for its all-pair program and for setting the Medicare rate of growth for the accountable care organization participating in the model and then again in 2018 the Greenback care board went through that process with one care Vermont evaluating its budget and setting its rate of growth for performance year two which is now 2019 and I want to say again Vermont's goals Vermont is certainly a leader we have a statewide program this program and you'll hear more about that from the board and from one care Vermont and from Diva the program is including providers across our state it's a statewide model and in that respect we are certainly a leader in having an integrated system that's spanning provider and provider types throughout our whole state but we're also in a model that's really consistent with the direction that the federal government has established that direction being established with the Affordable Care Act being reinforced by MACRA again and then I think we were all wondering if that direction would change with the change of administration and when it comes to value based payment that direction has not changed and the current administration is continuing to push value based payment and to assert that ACOs that take risk in are achieving good results whereas ACOs participating in shared savings programs were not as successful in achieving cost containment results so we see our federal partners continuing to move towards value based payment and I know that sounds like jargon but our federal partners are continuing to say fee for service is not where we want to be so in 2017 the Quality Payment Program was established and that was something that came out of MACRA so instead of providers being seeing their reimbursement rates updated through the Sustainable Grocery Formule which was not actually contributing to rate changes MACRA established what's called the Quality Payment Program the Quality Payment Program has two tracks for providers to participate in one is the Merit Based Incentive Program MIPS the other track is advanced alternative payment models providers that participate in MIPS have to submit all of their quality information to Medicare and then Medicare determines whether those providers get a rate increase or a rate decrease based on their performance so there's a lot of reporting for those providers and then what the outcome of that is is uncertain if their rate increases or decreases and as the program is fully implemented those rate increases or decreases can swing 9% up 9% down based on your performance when you say the providers who are you specifically talking about Medicare Enrolled Providers for Parts A and B Medicare and the advanced alternative payment model track allows for providers participating in the Quality Based Payment Model as long as they are participating in that Quality Based Payment Model and they are participating in their quality performance reporting in that model those providers receive a 5% increase it's the federal government's very strong in my opinion incentive to participate and so that's the history of that for now well I actually think that it seems there's a whole lot there but I actually think it's a little helpful to have a sense of where we were and how we got to where we are and where we are is let me see if I can read just say so we've entered into the agreement we've established an accountable care organization to implement the agreement with providers the state didn't establish there is an accountable care organization in the state it came into existence to do that and I think one of the significant things for me is there's a lot to understand here but that we are part of the way we are just really in the beginning years of a longer or what is it set out to be what a six or five or six year it's a six year agreement with five performance years right so it's so as we learn and understand more about what's happening for us to hold that in perspective as well we are we've entered into this agreement we've started to implement the agreement but we are not fully there are stages to the implementation we are in the relatively not early stage we are in the earlier stages of implementation which as a result of that we are in both worlds at the same time which is part of the complexity of where we are I think what I'd like to do at this point is I know this is a lot but to just kind of open it up for committee member questions about where we are at any questions actually at this point and then let me get a sense you have this point and then we'll be hearing from the Air Board so let's open up the questions for Ian at this point is that okay just to see where we're at I have one easy one I think can you give me an example of a Medicare provider yes or a couple of examples a primary care provider is most a provider does not have to enroll with Medicare but many providers do enroll with Medicare because there are many Vermatchers who are covered by the Medicare program and so a primary care provider is probably a great example of someone who's likely to be enrolled with Medicare your doctor someone who has Medicare has their primary source of health care insurance can go to that practice and they will accept them because they can then because of their agreement they can bill Medicare on behalf of the patient largely most providers in the state are likely enrolled with Medicare there are probably very few that are not to Brian's question just to clarify how would you know a provider is a primary care provider not only are these Medicare providers but how would you know that they're actually part of the accountable care organization process of changing payment I'm going to defer that answer to either one care or the Green Mountain Care Board which both are up to date with exactly how people are notified of the providers participating I've seen a sign in my provider's office that it is participating in the accountable care organization but I'm going to defer to those who have the right answer for you I was just wondering what other states of ACO systems do you know there are many ACOs operating in the United States many of those ACOs are maybe of one payer ACO so they're participating in the Medicare ACO program or they're participating in the commercial ACO program and or Massachusetts has a very large Medicaid ACO program there I have fewer examples of ACOs that are all payer ACOs but that's something that we could come back to to try to give you that answer that's part of the significance of this agreement is that it's all payer I mean defer that term and it doesn't necessarily mean something unless you maybe make the distinction that you said that when you hear accountable care organization it does not necessarily mean that that accountable care organization in another state or jurisdiction is trying to implement all Medicare, Medicaid and commercial together and if they are doing that they do not have an agreement like the state of Vermont does that requires them to be the alignment across those programs to be assessed and that's again something we heard really clearly from providers is that alignment across payer programs and a majority of their patients being in the same type of payment model would be really helpful for them in changing how care is delivered and improving the delivery of care so that's where Vermont is really consistent with the goals of the federal government but we are a leader as well the government is pushing this way and we're going at a faster pace can you say what the alignment means when you say to be in alignment across all the three different types of payers what does that actually look like there are a variety of ways that we would assess the Green Mountain Care Board would assess alignment and I think that they can talk to you about exactly what those ways are but an example would be what the contract looks like in terms of the payment an example would be an example might be how beneficiaries are attributed to the ACO in each of those payer programs that's a key area for alignment one question I'm not sure whether I should ask it now or wait until we've heard from the other folks but earlier you had a slide and then you alluded to a couple of times I think about reasonable targets and I'm wondering how reasonable has been interpreted up to this point anyway just in terms of numbers percentages the growth target that Vermont established at the all payer chart is 3.5% at the end of the five performance years of the agreement and we established that target because we wanted to see the health care system moderate to something closer to the growth in the economy but that is still higher than the growth in the economy and that's where that target came from through an assessment of what the historical growth of the health care system had looked like for 15 years and at the same time what economic growth had looked like for a 15 years span that's where the medicare target is one that the federal government really really pushed Vermont hard on in that Vermont is a very low cost state when we think about how many dollars we spend on medicare beneficiaries however the rate that we're increasing that amount of dollars is fast compared to other states and that's where medicare wanted Vermont to moderate our federal partners felt that Vermont should grow in the medicare program to percentage points below national projected medicare growth and that changes from here to here correct so that actually needs to go and my question which was are those, are the growth rates aligned in terms of what the expectation is for commercial medicare and whether they are or aren't how does that play into the whole cost shift issue because medicare could keep its growth rate down by increasing the cost shift and then that would make the commercial pairs more unable to keep that growth rate down that's what I alluded to when I talked about how Vermont's proposal had changed based on our year negotiation with the federal government and one of the things that I think came through in that negotiation which I think is a very positive change to our proposal and is something that we learned by working with our federal partners was for there to be an assessment of the payer differential for these per member per month payments for these prospective payments and that is something that the agreement on care board has to do I believe on an annual basis and it puts a spotlight on what those rates of growth are and how they differ by payer so it's something that we need that through this agreement we are able we will be looking at but the fact that they may be different doesn't fully identify the degree to which there might be an increase or reduction in the cost shift because maybe Medicaid is being more efficient and things like that and I know that the agreement on care board monitors the cost shift but I'm wondering to what extent the all payer model itself has any focus on where those cost shifts could be resulting or moderating it does have that focus in terms of asking that there be explanation for that differential between payers and in explaining that differential I think and again I'll let the agreement on care board speak to that that is where we would look to see potential recommendations for narrowing the payer differential and it would explore underlying cost and it's a very I think it's a fairly complicated analysis of that payer differential I have several comments first just a comment this all payer accountable model that was very streamlined very beautiful very simple but surely there must be issues with that okay just a thought I don't know and I understand trying to limit class of growth and limiting class of health care but by keeping these costs down I wonder by keeping the costs down what actually as far as the provider services that they provide to the patient and then finally you mentioned quality quality measurements your providers are doing all these things doing well first off I'd like to know what these quality measurements are that the provider has to look at and I'm also thinking you know we're getting away from doing the basic work of a physician which is to treat patients and not look at we have to look at the other side but it just seems like we're getting away from medicine and having to do quality measurements which physicians shouldn't really do that's my comment one piece of the one care Vermont and the Green Mountain Care Board can both talk about as well as Diva can talk about the quality measures and what they are and talk and explain that to you in the framework for quality measurement to you when I talked about the local control that Vermont has relative to the Medicare program one thing that I didn't mention that is very important is that and this is a two representative Donahue's question another area very important to alignment is are the quality measures aligned across the payer participating payers to reduce the burden on providers and our providers looking at the same and the same basic set of measures for their patients and the local control that Vermont has allows Vermont to propose changes to Medicare's set of measures so that Medicare's measures better match what we're measuring in Medicaid and commercial programs and that those measures also align with Vermont's specific priorities for improvement which are to improve our access to primary care providers to reduce the prevalence and morbidity of chronic disease in our state and to reduce suicide and drug overdose in our state and we reduce the Medicare set of measures and I'll let the Green Mountain Care Board speak more to that and have but we align those measures with our population health outcomes and that measure set was reduced so that it was in better keeping with our objectives as a state. Vermont has performs well in quality in some areas that many other states don't perform well in and that's why Medicare as a program has this larger set of measures so I think that's one thing that's very important about our flexibility with the agreement is are our providers happy with their system that we currently have? Are there issues? I think that there are issues and I think that there are also improvements that providers working in the system have already appreciated and have shared in a variety of ways. There was a Green Mountain Care Board meeting and again others did do attend that meeting so that's one one forum where providers were sharing about how they have changed care delivery in this model. So what I'm just going to pick up on one thing that I think is I think I understand that clearly but Medicare because it's the federal government paying for Medicare absent are being part of an agreement like this they actually have the federal government has the authority and the ability to impose whatever quality measures they want and is doing so through the MIPS program that I talked about that's split that you're talking about so I mean this is not to justify necessarily this avenue but if we weren't absent an agreement that gives Vermont more flexibility to try to shape Medicare's requirements because it's federal government and it's federal money they have a set of in this case quality measures which we would be required to meet regardless of what we thought we thought they were good, bad or indifferent so that's that's one piece of this and I would just I would just say because I think we're I think it's great I think all these questions need to get asked we're trying to some of the questions really are going to need to be directed to one care and to hearing from other folks about one care and so we're just going to it's going to be an ongoing process without we've got to hear from numbers of people and that's we kind of defer this piece to act across but there's a lot here to understand and to maybe raise questions about other questions for I want to just actually name the other question that you put a mark on the question you asked like what is being cut that is one of the fundamental questions that has been asked and needs to be asked over and over and over again are we simply going to achieve the targets by doing less is somebody going to get fewer services are they going to get inadequate services and therefore and when it's measured we go oh we met our target but in fact people were getting not what they needed but less than they needed and less than they would have got before and I think that's one of the that's one of the ongoing drum beats that has to be asked over and over throughout this whole process and it has been you know it's the question that always rises immediately as we talk about this needs to be talked about followed out regularly it's not something that just can get answered once and be done I hear you're naming something that has been asked before and will need to be continued and the other drum beat which may not be for you right now maybe other players but some of us are aware that mental health and substance use are not fully integrated into the all-hair model which is needs to keep being asked about that movement and the fact that that does not meet our principles for mental health care so there's lots of pieces to think Mark just a couple comments I would echo for an area of concern I have about how we move forward with the value based and I've been a supporter of this process while we were working towards Act 48 so I've felt along with Helen Ramsey and everyone that was really rallying to get this done I appreciate it and as someone who works in the health care system one of the concerns that I do have are and I know we're working on it is those quality measures and if re-admission rates are part of them are we seeing sometimes early discharges that will lead to higher re-admission rates but I think built into the system is if we are discharging people too early too soon it's going to come back to by us because they're going to be likely re-admitted sooner and the other one is patient satisfaction scores I think those are really hard there's a lot of subjectivity in so I think those are patient satisfaction scores are really hard to use as a quality measure and the last thing is what alignment along IT and medical record are really key in being able to have standardized quality measures for all the providers so I think that's an exciting part of this work not too surprising but I think we I'll say I those of us who are planning our agenda may have been not more than we could chew this morning in the time that we've allowed but I think I think this is a piece of kind of laying the foundation for the next pieces and I'm thinking we had we had scheduled this to go till 11 I'm not sure what your availability is to go a little bit past 11 or some past 11 and I know some others but at least we may have to invite you back so so and I think Sarah Squirrel was scheduled to be presenting us something at 11.15 I think we're going to see if we can be in touch and push that back a little bit 11.45 probably because it's a more it's a brief update for us could we agree to go till 11.30 on Susan Barrett looking to you and Michael so then get in that I'm going to suggest we take a quick stretch between well I'm just trying to check this out guys like how did how did let's take a quick stretch and then come back and work with Susan Barrett I think we're going to need to turn to Alicia another important topic and then we'll have Sarah Squirrel during the break we we are going to do our best to have attention for this presentation there are folks who are going to be coming and going from our committee policies but there's other things that are pulling people's attention as well but what I'd like to do is to turn this over to the Green Back Care Board to help us understand more from the Green Back Care Board's work about how Barrett turned out to be Susan Barrett thank you I'm Susan Barrett and the Executive Director of the Green Back Care Board and up front I want to excuse my raspy voice like everyone in this building and I'm joined here today by Knight Barber Knight Barber is our general council for three weeks but it's important for the committee to know that previous to being the general council Mike was in the role as Chief of Health Policy the role that Ina vacated when she went over to the agency so that's actually good context I also want to introduce Melissa Miles who's one of the project directors for the Green Back Care Board and works very closely with the all pair model and the ACO regulation so Mr. Chair what would you like me to do would you like us to go through the slides or address some of the questions is your pleasure okay I could start with the slides some of them may end up being opportunities to integrate to the question as you because I would like you maybe to start to go through them and maybe what we'll given that we only have we have till level 30 but I think maybe it makes us look at questions more in a way because we're not going to have so we'll ask you if you can please and I'll also say that we will make sure that we are in the room as you hear more testimony from our partners at Diva as well as the ACO I think it's really valuable for all of us to be in the room together so we will commit to that great so high level overviews and goals for us today if you ever wanted to answer your questions to provide a reminder of the all-parent model goals very quickly which I highlighted I want to talk it is important for us to talk about the Green Mountain Care Board responsibilities in the models to dig deeper than what Ina touched on and then to give you a status update on the model and the role of the board in the oversight of the ACO as well as our work in the implementation of the all-parent model Ina went over this but it's another way to hear it and to look at the goals of the accountable all-parent accountable care organization model we are as a state testing payment changes so we're looking at the payments testing them in a population-based payments that are tied to the quality metrics we are increasing investment in primary care as a goal of the model and also monitored closely by the board as we look at the ACO budget we're looking to transform care delivery again Ina touched on that as well but really focusing on care coordination I'll just address the question what isn't being done I kind of went to that in my mind like what Kennedy said what can you I'm going to get the quote wrong but don't ask what you can do yeah thank you but I went to the opposite side of that question of what is being done and what is being looked at in terms of care coordination with providers what is being done upstream to prevent illness is something I think you care more from the ACO and some of their providers and then incorporating social determinants of health which is a key part of this model and then also the goal to improve outcomes and we touched on these high level goals these are in the agreement the state has agreed to improve access to primary care to reduce deaths due to suicide and drug overdose and to reduce the prevalence and morbidity of chronic disease these again are the very high level goals and then the quality metrics are filtered down through the ACO and then down to the providers a provider does not individually is not being held to reducing deaths due to suicide and drug overdose that's a very big distinction that I think I should make where do we characterize testing and payment changes just right over there in the left in the previous testimony we heard that as far back as 25 years ago there were pilot programs going on so is the current agreement that we have I mean is it described officially as a test and does that mean as far as that there may be tweaks and changes over the course of the five years it's not my colleague Mike will correct me if I say this and Ena me too but not say test in the agreement at all I don't believe it does but Vermont is a very small state and the ability for us to again touch on this as well we are far ahead of payment reform health care payment reform efforts and the ability for providers to come together voluntarily to work on new ways of paying for health care is perhaps easier to do in a smaller state like Vermont and it would be in California so I don't know if I answered your question but it is it is not officially in the agreement called a test but we are looking at these models in the success of the agreement with federal government and going forward if this does not work then that is information that can be used going forward does that make sense? I think along that line the governor was on one of the television programs just in the last few days and he referred to it as a pilot again and I think that that's sometimes confusing for people I'm just to understand that this is this is as you described it's an effort to try to understand what can be achieved and to work toward achieving it but it's not technically a pilot idea according to the agreement this is not a test but that's some people understand it as what did you say? in the lead in language the testing and the payment follow great I believe we talked about this Mike I don't know if you want to touch on this this slide is Ina talked about the general goals of the agreement the targets of the agreement and this slide is just trying to represent that obviously as a state as I said this is an agreement between the state of Vermont and the center for Medicare and Medicaid services the goals of that agreement are reducing the growth of healthcare spending or cost increasing population health goals and improving quality and then increasing alignment of ACO programs operating in Vermont and increasing the scale of the number of people who are and providers who are part of this model and I guess you can read the slide but the point I wanted to make here is that and I think Iina touched on this is that the goals around alignment and scale are really intending to ensure that providers have consistent, strong incentives to do the cost containment and population health investments and efforts so really these two kind of boxes are intertwined so it's very important that we increase scale, achieve alignment to get to the cost containment growth and the population health improvement and the scale growth yes we have a slide for that so we do not have to report to the federal government on our scale performance for 2018 performance year one until June of this year and then we'll be recording on performance year two for 2019 in June of 2020 we have a good idea of where we were last year and where we expected for this year in terms of scale essentially we are behind where the agreement says we should be we are on the right trajectory so the increase in scale from performance year one to performance year two is in line with the expectations in the agreement but we started from a point that was too low and and so we're going to add to that's one of the things that I think the ACO is very focused on it's one of the things that we are focused on and the justice focused on is increasing the scale getting more payers and providers into this volunteering model I know you're just scaling up and it's just way too early for any of this but are you seeing any results where it's around state even though the state is small as you're scaling up any results where it's harder to implement in some areas and what the outcomes may be I would say no I just moved it to this picture just so you know each community has its own unique challenges so for example my understanding in the Rutland area there was an issue about the hospital not having primary care practices all the primary care practices being at the FQAC and the hospital accepting risk but really not getting the benefit of some of being in the ACO other areas the hospitals looking at the risk for these programs in terms of budget and their specific circumstances and specifically the Medicare risk which is quite large compared to other payers so I mean each, I think we've heard stories about challenges in a lot of different communities and it's kind of each community's specific circumstances but this slide is showing the geographic growth of the program from performance at zero in 2017 to Medicaid with the risk based program to 2018 and then 2019 where only two communities are not in for at least one program and I'll add with those two communities one is the Copley area and it's the same situation that Mike was describing in Rutland where the hospital does not have any of the primary care that's all at the FQAC that area and then the other area is Grace Cottage area which is a very small hospital more very hard for them to take on any risk so that's I think a good point of some of the challenges different areas are facing Can you go back to the scale and just kind of give us a sense of it so Mike you mentioned that I'm not sure if the numbers in front of us shows where we are or these are the goals so there's there's two targets for each year there's a Medicare target and we all bear so the Medicare target for performance year one 2018 was 60% in our performance we think preliminarily was 35% for the all payer target it was 36% our performance was 20% for performance year two the Medicare target was 75% we're at 51% we believe all payer target is 50% we believe we're between 30 and 40% depending on what happens with some contracts that one care is working on I think the takeaway is not where the agreement says we should be but we've done a lot of work and we're on a good trajectory and kind of in line with what the agreement expectations you mentioned I guess it was probably maybe some other hospital it was having difficulty getting primary care providers what if they just can't get the man power let me clarify in the Hopli area as well as the Rutland health service area the primary care providers are exclusively part of the FQHC and they're not part of the hospital and the way that folks are what we call attributed to the model they are attributed through primary care providers so if the hospital does not own any primary care providers they cannot participate in the model they have to partner with their FQHC but the hospitals are the ones who are participating with the risk it is a result of historical changes in the way primary care was owned going back to the 90s I know that Rutland hospital used to have a lot of the primary care and they migrated over to the FQHC it might not have been the 90s previous years it is just the way some communities are set up that way just based on historical migration of practice they don't change they can still participate the community can participate as a whole it is easier for hospitals who actually have primary care in the hospital UVMMC is a perfect example they have quite a few primary care providers that are owned by the hospital employed by the hospital does that make sense no it doesn't hopefully sitting in the middle of this area still light green why do they even need to think about participation it doesn't seem to make any sense to me probably because I don't know why even bother with this so far they haven't they haven't bothered what's their advantage when they do what's their advantage what's the incentive for them to participate what would be of value to them I wouldn't mind you to ask that to one character when they come on Tuesday but I think the advantage is the potential for savings if you perform better than expectations right that's kind of the model that we have we have targets for the ACO based on here's what we think spending will be in the upcoming year and if you the ACO beat that target you get savings those savings in large part go to the hospitals that are on the flip side taking the risk so what you're saying is if someone elects to go to the hospital they can go to Newport and save money that's what it sounded like we're talking about at the provider level we're not talking at the patient level and I think another addition to what Mike has shared in terms of and the ACO look at them as well can address this as well and it relates to scale this model and the support that the providers can get from the ACO and care coordination and population health in education around their way of providing that coordinated care in order to at the end of the day to provide savings to the system in the whole will be the incentive for places like Cochle and that community to participate in the model and it has to be this is a big scale question it goes beyond the providers it goes to self-insured plans and I'll get another slide and I want to make sure we get to in terms of the role of the board but we need to look at what are folks paying for health insurance and if there's a business in the state who wants to part the working within the model our insurance premiums are predictable and affordable that's an incentive to join the model and I'm getting ahead of myself the bigger picture that I think folks need to understand and it don't get there, I think you need to hear from the ACO as well yeah, that's a good try then put all these pieces together in the meantime, Woody and then, Ann Marie you talked about risk it seems to me that a hospital if it takes risk in providing an additional services that are not provided elsewhere that they have a great opportunity of being profitable I know they're non-profit but it seems to me those risks might be beneficial to certain hospitals in finding a niche in the work that they're doing just an observation I would say more aligned to the incentives of population health and yes they are taking on the risk of that population and I'm sure they don't take it lightly as well absolutely but there are benefits to ensuring that risk in whatever area that they're going potentially, but that's the point of the risk Ann talked about that two-sided risk in the past there's only upside risk and there's two-sided risk so the incentive again is to get ahead of health issues that could impact the cost of care of the patient and as well as keeping that community healthy yeah okay yeah yeah yeah and we're talking about incentives for them too but the other side is will they eventually be squeezed to participate this is a voluntary program I know it's voluntary but will market forces and stuff like that squeeze so I think Ina had talked about kind of the push at the federal level to this is one model so I think providers are being pushed towards value based payment across the board and this is one option that providers have to join this model to get support and resources and help managing their population from an ACO so I think in part yes providers are being squeezed but but in the broader push towards value based payments at the national and state level this is happening at the federal level it has been happening I think the point Ina made about the transition to the new administration one of the biggest surprises I had was the continuation of the value based focus that's a great question so this is a map just of the hospitals in the state which ones are participating so back to the previous slide then that had the scale numbers these numbers represent a larger pool of some sort of providers beyond hospitals but can you define what that pool looks like and is it one of those slides maybe we jumped over it I just want to point out there's a fairly detailed specification that we have developed and confirmed with the federal government about what populations are in what populations are out but essentially Medicare scale targets we're talking about all Medicare beneficiaries for the all-heir scale target there are certain groups that are excluded like people in tri-care and federal programs uninsured obviously but for the most this is not providers these are people patients and the other map was providers and participants so that's a very good distinction just because I was a little confused but maybe maybe we've seen it before you're differentiating between Medicare and all-heir here so all-heir is not really all-heir if you think of Medicare as a payer it's all acceptable well, Medicare's I think when they use the term all-heir when they use the term all-heir on this slide that includes Medicare it doesn't it targets exactly you're breaking it out but all-heir still includes Medicare and there are on scale on quality, on cost there are separate targets for Medicare and like other payers because Medicare was keen on us well, at least on the cost side obviously demonstrating savings to the Medicare program and the value to the program and can I go to one other slide before so we can get this in today because this was I just told Mike this is my favorite new slide because I wanted to make sure one of the goals that I had for what I wanted to share with you today is the distinct role the board plays in the all-heir model and somebody had earlier was what other states are participating I think it was ACOs you'd asked about ACOs but someone else in the room can correct me if I'm wrong there's only one other state that participates in all-heir model with the federal government at this time and that's Maryland they participated for many years but they had a newer agreement that was negotiated around the same time as ours a little bit before but the distinction that I want to point out to all of you is that while negotiating with the federal government the role, the existence of the Green Mountain Care Board and the regulatory structure that the legislature had created within the state was one of the key reasons that the agreement was able to go forward Maryland also has a similar type of a board it's much larger but it is also a board that has regulatory lovers that can support the success of the model so I just wanted to make that clear to everyone and when you look at the two goals that the board has and the mission of the board which is to reduce the rate of growth in healthcare expenditures as well as to ensure access to high quality care these levers, the Medicare ACO program design and rate setting which is part of the all-payer model the ACO budget review which you gave to us as part of Act 113 2016 as well as the certification of the ACO and then these other levers that we've had in our purview hospital budget review health insurance review and certificate of need all of those combined are really a quite a benefit to the success of this model and to the support of the success of the model so I just wanted to make sure I got that out a bit of a plug but Shane Leslie playing the board so I think we should get back to some of these the beginning some of the reporting we do does that work? I think that's really important to hear where where we're at so as Ina mentioned I think the board is responsible under the agreement for developing the Vermont Medicare ACO initiative which is basically the ACO program that the federal government offers through the agreement and we kind of do two things there we set the Medicare benchmark or the financial target that's part of that program for the ACOs that won't participate in that program and we do that annually some parameters in the agreement in terms of where we can set that target and it has to be approved by CMS so we've worked closely for the past two years with CMS on the benchmark methodology and it's developed and have established how does that really be yeah I know it sounds like a lot of jargon what does it really mean not serious I don't mean to be critical but it's just like what is sending it's setting of an annual Medicare benchmark why why is it that's valuable setting a target for the ACO to meet a spending target this is we have a certain group of people who are aligned with the ACO and the ACO is responsible for the spending and quality of that group of people these are the attributed lives that are attributed to the ACO for Medicare and you are one of your responsibilities is to set a goal for a ceiling of what they're not supposed to exceed in terms of increased expenditure on an annual basis so there's a certain set of services that the ACO is responsible for a certain group of people who are responsible for the attributed lives and then the benchmarking I think it's easier to think of it as a financial target because we're setting a target for the spending for those services on those lives in the upcoming year performance period and it's complicated but essentially it's taking a base claims experience projecting that forward to the performance period and that's the ACO's target and then as part of the two-sided risk this is a two-sided risk model so the ACO is at risk if it spends over that target and if it spends under there's some savings obviously quality is incorporated into that and its performance on quality measures impacts how it does financially but that's the general just as if you go over the target you're going to have to pay some money back to Medicare or another payer if you achieve savings over what was projected to be the spending then you get some money back and I think the key one of the key pieces here is that it's not like the ACO is like so where do those savings go if the savings so I think that's important to talk about what happens with the savings if there are savings if there are savings then first they will go to the hospitals because they are the ones under this model that are taking all the risk so there's a distribution formula there's three steps there's a policy on our website a distribution policy but essentially it's first to the hospitals for the risk they're taking hospitals are also contributing a lot of money towards these programs, population health programs so the money that's going out to primary care the money that's going out to community providers if there's savings the hospitals get reimbursed for that and then if there's any excess savings beyond that there's a formula that's basically the same as paid out under one care's quality with holding programs so that's 70% primary care providers easy answers it goes to providers I think that every day it all goes back to the providers whether it's the hospital or providers it's not like it goes into a savings account in ACO there's a misunderstanding thank you for bringing that up okay so I'm wondering about the scenario where rather than savings it turns out that there's more spent I've heard you say two-sided risk so does two-sided risk mean I think I understand now but does it mean that there are two different parties sharing the risk or is all the risk on the providers here and if that's the case if they are spending more than the target are they eating all of that are they really bearing all the risk I guess so it is shared risk they are not bearing all the risk so there is in all of these programs that we've seen so far there is a cap on overages ACO would only have to pay up to a certain percentage of the target so for Medicare this year it's 5% over the target if if they blow their target by more than 5% then that is even by the fact so it's a sharing of risk but it's limited it's not like an insurance company it's just totally at risk yeah and I know this is it's great we're getting this out here for the first time because I think the ACO can really convey these steps at their level and I think that's a really important question for them as well but it's great to hear it for us too no I'm just saying that's why it's important so that we're actually able to ask some of the same questions and have it understood I think I'll save my question in the direction my question is more holistic we talk about how we're doing all this and we're saving money we're trying to do this and we often hear how Vermont's health insurance rates their costs are lower than other states under this I know it's early but how is Vermont doing compared to the scheme of the rest of the country just in general I'm sure we don't need that because people are saying they can't afford health insurance they can't afford if they do have health insurance to to participate but yet we hear from Vermont's rates are much lower than the rest of the country it's just that everybody always complains about taxes and health care costs is there some substance to that complaint so I think we go all the way back to what Ina started with and how we got here and I wrote down a couple of things when you asked I think it was the chair who asked what brought us here and yes Vermont is a lower cost state when it comes to Medicare per year but it is still too expensive and that is how we got here excuse me and was growing faster so there is still work to do and this model attempts to get to that underlying cost of care and we're two in the model I think personally in order to see success we need to see that scale targets increase so that we can literally scale this model so I don't know if I answered your question but it's a tight question to answer so let me just I know we haven't gotten to cover everything that you prepared for us and thank you for indulging I think it was useful for us to ask questions along the way I think I'm just going to offer a couple thoughts and maybe one character can help respond to and then you in future days it's a little bit like we're in catch 22 of sorts it seems to me that we're not at scale and we're not at scale over time in any case but we're not quite at the level of scale we like and until we get to scale it's hard to actually see the full benefits and experience the full benefits of the alignment so that the providers are only dealing with I mean they're not having to deal with differences from commercial from Medicare so we're probably the most difficult I'm thinking that we're on some ways we're neither here nor there and so some ways we're like in the most difficult point in time of a change like this because the providers can't fully experience the benefits if there are going to be benefits and yet we're asking actually people to participate in multiple ways even though the goal is to not have that be the case and we're asking for more people to participate based on our hopes that it's going to be better and some of what has been experienced so far but we're not far enough along to actually prove it all it's like it just seems like a conundrum of I mean that's how I'm perceiving it right now and I just I don't know what else to say other than that and that this is a complex process of trying to achieve some major structural changes within healthcare that I think the goals many people maybe not everyone but many people share the goals the question is this level of complexity and expense worth achieving the goals that have been set out or are we and so I think that's kind of like those have to be some of the questions that people are asking along the way people around this table but also people and people participating so those are the things we have to work on. Can I just say one thing I think you should hear from the ACO who they can have her now which I really pleasure I'm a glass half full person there are challenges and this is a ton of work but it is extraordinary he has to go how much progress we have made actually this graph is one of my other favorite I mean this is from the first year of the model to today there has been significant uptick in participation and it has been gradual which we have heard from the our federal partners that that may be a benefit as well because in other states where different programs were initiated if things went too quickly there's a risk there as well so I'm not I'm being I'm trying to not be too rosy but I do think that this this is very impressive what the providers have done to date but I do like in our where we are right now to kind of like adolescence you know like a tween age where it's growing and we're at a point in our model I'm looking forward to your one care I have the opportunity to sit down with one care apart from the committee and I think there's pieces that here about what is actually happening on the ground with some providers and what one care has been able to is able to bring to the actual patient experience and provider experience and that's we're all talking very theoretically here and I think that's really contributes to the complexity the difficulty of understanding why would we be doing this and why are we doing this and what's the value here and I just I appreciate that it's you know like these are great questions and from my perspective at the board we want to answer all of your questions it's really hard because it's so complex it makes my brain hurt a lot so I think the more we can have these conversations and answer your questions is positive for all of us it's actually essential for us you know and so with that I think we're going to stop for this morning I'm going to express my appreciation to you and to Keene and to Mike and to the committee I'll just say I kind of I'm not trying to sell this but I just kind of hang in there because I think there's more pieces to hear and the questions are actually important I'm not, the questions that are being raised are the same in many ways the same but also important questions I'm not like I don't mean that in a dismissive these are the questions that need to get asked as we because we are in the midst of this right now and then policy questions come up for us as a committee and the legislature is like where are we, do we continue what kind of what kind of oversight should there be is there enough oversight, is there too much oversight is there this and that but in order to answer the policy questions that emerge we need to actually understand this more fully and it's a choppy way to do it and we're turning our best to try to now layer in a whole new set of information and there are plenty of questions and it's not like it's a smooth it's just completely a smooth ride so I'm going to suggest we stop there for now, thank you Susan and we'll look forward to hearing from OneCare on Tuesday afternoon and maybe we can have some conversation ahead of time as to how we can best set that up for the committee to be learning about what OneCare is actually doing so for the committee we're going to stop here on this looking for can we just stay put for a minute I'm looking for Ian Donahue who I think was arranging for to communicate with us by phone rather than in person to give us a brief update on another small piece around children's inpatient access if your brain hasn't exploded this morning I've said it so many times but if you we don't as you've noticed we don't pursue one issue in your way until it comes to completion it's not possible and that's part of what's difficult about our work as a legislature in case you're wondering it's happening in every committee in the building but we just kind of have to keep shifting gears I'm starting to think that we're knowledge about a lot of things you could you know after this