 Welcome to the future, Joe. Listen, we're all going to be good. We'll take good care of ourselves and washing our hands. And I'll just speak around each of us. All right. And this afternoon, just FYI, at 4 o'clock, we'll be meeting in room 11. We may have to move up to the other side of the house, but we'll be in room 11 to talk about COVID-19 and the coronavirus. And here from the Department of Health and the Agency for Human Services, we'll talk about that a little bit later in the morning. So today, we have S290 on the agenda. Jan will be down in a few minutes. But I want to point out to everyone that there is the bill, draft 1.1 that we looked at previously, and then there's a new draft, 3.2. And that is based on some of the testimony that we've heard, the input, especially from the Rebound Care Board, and then the thoughts that we had about putting some of this into a study and working with the folks. So the section of the bill, I just want to point that out to you. I don't have time. Jan is here. How are you? I just want to ask that there's a new draft of this bill. There is. I think that the main goal today on S290 is to listen about the new draft a little bit. We'll go through it from the thousand foot level. And what we do want to get to the part of VFR and the Ramassini employees and human resources so we can listen to any concerns and then be any ideas around the study that's in the bill at the end. So, Jan. All right. Jennifer Harvey, Legislative Council. I do have a bunch of bills on House flip today. So I'm going to be in and out. So we'll do what we can do with the draft. All right. And try to figure out how to keep track of the floor. So we have a new draft that you all have. Do you have the draft? Yes. Okay. It's draft 1.1. It's draft 1.1. I have glasses on. You can add it right after I printed it for discussion. Okay. So I started out doing all the markup stuff. But it's... Great advice. Sorry. Sorry. No need to apologize. You're defunded isn't it? No need to apologize. She said there's no need to apologize. Okay. So I started out doing this as a markup showing you everything that was, you know, striking out everything. But it's so different that the whole thing ended up bright yellow. So I just started. It's basically a new document for the most part. So section 1 on oversight of accountable care organizations, most of what was in the bill as introduced is out. There would just be a requirement that in the Green Mountain Care Board's review of ACO budgets, the board, as part of its consideration of the information on the ACO's administrative costs, that would include the annual salaries and benefits by position for all of the ACO's level employees. And then a few new provisions added to the end of that in the budget review. The ACO's efforts to... Whoops. Should be educate. This is unedited to play up with that in there. Educate providers on best practices and protocols for patient management. And the ACO's outreach efforts to educate providers in the public about the ACO's mission, its initiatives, and its impacts to date on population health. Then section 2 would be a requirement that the agency of human services in its contract... I'm sorry. Actually, DFR. In its contracts with a certified accountable care organization, the DFR would require... I'm sorry. Coming from too many different places. Let me slow down. In its contracts with a certified ACO, DEVA would require that the ACO consult with the agency of human services, that's where they're in here, and its departments regarding public health and population health issues and to coordinate its services and initiatives in these areas with agency and departmental programming. So some of this was in requirements for grant and care board certification. One of their recommendations was to move it to a requirement that DEVA put it in its contracts with the ACO's. So that's what this would do. Section 3 is a new study on regulation of ACO's and the future of the all-pair model. This would direct the Joint Fiscal Office to contract with a qualified independent external organization to recommend to the General Assembly the most appropriate manner in which to regulate ACO's and to recommend modifications for future regulations of the all-pair model. On number 4, January 15, JFO would provide to the committees of jurisdiction, in this case I put that this committee, Finance and Health Healthcare and the Appropriations Committees, the external organizations report which shall include recommendations regarding a model for regulation of ACO's that is feasible for Vermont, methods for increasing an ACO's transparency and accountability, including whether to require an ACO to establish a policy linking the compensation for management level employees to the ACO's financial and quality outcomes. Ways to ensure, I realize I'm totally not doing the thousand foot level. I don't know if that's what you want or you want. I haven't seen this before either. Ways to ensure that an ACO fosters collaboration among its participating providers, including hospitals and community providers, and has established appropriate mechanisms for evaluating the extent to which these providers collaborate effectively. So that's a piece from the bill as introduced that was carried over to here. Ways to encourage the ACO to engage in ongoing and multi-year relationships with its participating providers and to promote the development of sustainable programs and initiatives. Whether and to what extent provider solvency should be considered in the distribution plan for shared savings realized by an ACO, whether ACO budget should be set on a multi-year basis, and I think there may be more to come. So I put in a little placeholder there, but this is to get some of these ideas from various places in here. Then we would move over to hospitals. This would require, as part of their budget submissions for hospital year, fiscal year 2021, so that's the one that's coming up this fall, that each hospital report to the Green Mountain Care Board the services that the hospital provides, should be, hospital provides at the highest cost. And then on or before December 1st of this year, the board would compile that information and provide a comprehensive summary to this committee and House healthcare. So we might be able to predict what the highest cost would be this year. Sections 5, 6, and 7 are based on proposed language from the Green Mountain Care Board. So this is some information that the hospitals would provide to the board as part of the hospital budget review process. So this would add that the board, in addition to adopting uniform formats for certain data and information that they would include one for reimbursement. So they would adopt a uniform format for hospitals to use to report reimbursement information. Then in section 6, as far as the information that hospitals have to file with the board for the budget review, it takes out a reference in subdivision A2 for the financial information to rates and charges because that gets fleshed out in more detail in a later new subdivision that comes on the top of page 6. And that would be the hospital providing reimbursement information including commercial rates, charges, fee schedules, reimbursement methodologies, proposed reimbursement increases or decreases, and rates as a percentage of Medicare or another benchmark determined by the board. And then in section 7, an existing provision that requires all information filed with hospital budget reviews to be made available to the public. This would say, upon request, this would say, provide a reference to an accordance with the Public Records Act and then give an exception, accept that the following information shall be exempt from public inspection and copying under the Public Records Act and shall be kept confidential. First, information that directly or indirectly identifies individual patients or healthcare providers, that's kind of similar to the existing exception. Then reimbursement information submitted by a hospital pursuant to section 94-54 of this sub-chapter, accept that the board may disclose or release information publicly in summary or aggregate form if doing so would not disclose trade secrets as defined in the Public Records Act and financial information the board collects to address financial solvency issues. And then it gives a notwithstanding for the sunset provision. There's a sunset on Public Records Act exemptions, new Public Records Act exemptions. This says notwithstanding that this information will continue to be confidential. And then it also would add a new subsection B, notwithstanding the open meeting law or any provision of this sub-chapter on hospital budgets to the contrary, the board may examine and discuss confidential information outside a public hearing or meeting. Then we get to the Green Mountain Care Board itself. So this language about a healthcare provider being on the Green Mountain Care Board has not changed from the version that you saw in the bill as introduced and the version that you passed out of the Senate last year. Section 9 is a replacement for the language having the Green Mountain Care Board do the extensive budget review for the DA's, SSAs and Preferred Provider Organizations. This first carves out the Preferred Provider Organizations, although it has somebody take a look at whether they should have their budgets reviewed in a later section. But it would have the board do the kind of more limited review that they do for the Brattle Borough Retreat and Ambulatory Surgical Centers. So this would have the board collect and review data from each Community Mental Health and Developmental Disability Agency designated by the Department of Mental Health or DALE pursuant to Chapter 207, which may include data regarding a designated or specialized service agency's scope of services, volume, utilization, pair mix, quality, coordination with other aspects of the healthcare system and financial condition, and I've added including solvency. The board's processes shall be appropriate to the designated and specialized service agency's scale and their role in Vermont's healthcare system, and the board shall consider ways in which the DA's and SSAs can be integrated fully into system-wide payment and delivery system reform. So a couple of little changes to differentiate them from the Brattle Borough Retreat, also recognizing that there is some work underway to integrate them into payment and delivery system reform, but looking at ways to do so more fully. Then we have the Green Mountain Care Board Rate-Setting Payment Reform Report. So this is the Green Mountain Care Board Report Back on Things Report. Some of these were based on language provided by the board in response to as 290 as introduced. This was required by January 15th, the board to report to this committee and House Healthcare and Senate Finance. First, the estimated personnel and other resources that would be necessary for the board to exercise its authority under 18 VSA section 93-76, that's the Green Mountain Care Board Rate-Setting Statute, to set provider rates both for fee-for-service payments and under various fixed payment models including global budgets for individual hospitals and global budgets for the hospital system as a whole. The projected impact of rate-setting on the total cost of care under the all-payer model and on the sustainability of rural health care facilities. The manner in which specialty care shall be incorporated appropriately into the all-payer model and analysis of the increases in health insurers administrative expenses over the most recent five-year period for which information is available and a comparison of those increases with increases in the consumer price index. So this is taking out that health insurance rate review piece from the bill as introduced and changing it into an analysis and a recommendation regarding whether the board should conduct limited budget reviews for preferred provider organizations. So that's where that language goes in. It would require diva and health insurers to provide to the board upon request data on their reimbursement amounts as needed for the board to comply with the requirements of subsection A and that data shall be exempt from public inspection and copying under the Public Records Act and kept confidential. Then we have a study looking at the role of the Green Mountain Care Board and others in health care regulation and health care reform. This would direct again the joint fiscal office to contract with a qualified independent external organization to evaluate the structures and processes by which Vermont currently regulates and oversees the health care system and by which it fosters innovation in health care reform and to recommend redistribution of responsibility and authority as appropriate among the Green Mountain Care Board, the Agency of Human Services and its departments, the Department of Financial Regulation, the Office of the Attorney General and other public and private stakeholders. By January 15th they would have the joint fiscal office provide the report to the committees of jurisdiction which shall include recommendations regarding first which entity or entity should be responsible for developing and implementing health care reform initiatives, conducting health insurance rate review, regulating health insurance including ensuring insurer solvency, reviewing the budgets of hospitals and other health care facilities and entities, certifying and overseeing accountable care organizations, issuing certificates of need, providing health insurance consumer protection, containing health care costs, monitoring and regulating health care safety quality and access, licensing and regulating health care providers and health care facilities and setting equitable health care reimbursement rates both in and outside the all-payer model. Second, whether it be useful for purposes of health care cost containment for hospitals to report when they increase the commercial rates for certain health care services and I think there's more to go in here but I ran out of time. I left some placeholder language in for section 10 on health insurers about providing reimbursement rates to the Green Mountain Care Board and the Green Mountain Care Board keeping that confidential. The board had proposed that in connection with the hospital confidentiality language but it didn't seem to make sense to live in the hospital budget review section. Then we get to the fair contract standards which is largely unchanged from the bill as introduced except it took out the part requiring or referring to the Green Mountain Care Board reviewing the contracts and rates because we took that out of the other part of the bill. Section 13, another one I did not have time to do, would be added with an AHS workgroup working with the Department of Financial Regulation, the Green Mountain Care Board and other interested stakeholders on a proposal for regulation and oversight of provider rates and contracts. This is something to take the place of that piece from the bill as introduced and then just a section number change on the public employee attribution to the ACO and all-pair model report and then effective dates would need obviously to be updated. So good. Any questions for Jen right now? I'm sure you're all good. Sure it says none all of it. We need to go through and read. We'll kind of digest, yes. I mean obviously going through all the testimony that we've heard and especially from the Green Mountain Care Board and then thinking about what makes sense going forward and after having spoken with data backers and Secretary Smith and others I think we can make some progress on the bill. So please read this. I know everybody in the room is very excited about it. But there's a lot in here that I think responds to some of the concerns that exist about all-pair ACO and regulation overall. So I think maybe we'll just keep working. Okay thank you. Very good. And we will come back just at what? We'll keep going on the bill. Jen you're in and out right? So we still have two more bills. So when you're in at some point we'll look at the other two bills. But I wanted to just remind everyone that we have some time toward the end of the week where we'll be spending a lot of time on this bill. So there's time for everyone to go through it with a fine tooth comb and we'll get together on that. So we have DFR. Jill Rickert is here. Thank you for being here. I know that you probably looked at a prior iteration of the bill and that's okay. We really want to hear your comments about rate setting and the work that you do with the insurance company and what toes we're stepping on when we start writing legislation. So thank you. Jill Rickert I'm the director of policy with DFR. I was actually prepared to comment on section five, sorry I'm not sure which section it was actually. Section nine of the bill which would have given the Green Mountain Care Board authority to review and approve health care provider contracts. And my testimony is now sort of like you say no longer necessary because you've changed it to a work group to look at regulation and oversight of provider rates and contracts to include DFR, Green Mountain Care Board and other stakeholders. And I think that's great because there was a bit of overlap if you were to have done what the original bill proposed and if it's helpful I can just tell you what our role in provider contract review is. So we have a regulation 2009-03. In section 5.3 of that regulation governs provider contracts, fiscal incentives and disincentives. And there are certain substantive provisions that govern what may be and what is not permitted to be in a contract between a managed care organization and a provider. Examples are that we prohibit providers from disclosing information to members about the contract or the plan that may affect decisions about the member's health. We prohibit offering inducement to providers to forgo medically necessary services. There are sections that say a contract must include requirements and responsibilities of the MCO and providers regarding administrative policies such as payment terms, confidentiality procedures, et cetera. So while we do not review provider contracts as a matter of course, we don't require these to be filed with us. We don't approve them. When there is an issue that is brought to our attention by our provider, for example, or by an MCO, we review the contract and determine whether it's in compliance with our regulation. And we would appreciate being able to continue doing that. And I wasn't quite sure what was intended by shifting the responsibility to agreement on care board if the DFR would retain that authority or what the intention was. So I do think the working group is a good idea so we can work out the whole universe. Yeah. So the question, I just have a question about, as you were speaking, you were talking about managed care organization and we're now moving into an era of accountable care organizations which are significantly different, I think. So is there any thought on the part of DFR to modify language related to how are we doing that? How are we looking at ACOs versus managed care? In this reg? I mean, I think there are probably a whole bunch of regs that we would need to look at in that area. And I'm not, I don't know if there have been conversations in our insurance department about that. I would be happy to talk to the right people and find out what they're thinking, but I'm not sure I can answer the question right now. That would be very helpful because I think there is a misperception out in the real world that managed care and ACO are the same and they're absolutely not. So I don't know whether they're financing. What? So that would be like that, right? Yes. But that would be very helpful. I mean, one of the difficult things that we have is convincing people that the all-payer model and the accountable care organization which are going in glove are valuable to our state and healthcare reform. So it would be helpful to have that information. Sure. And then your interest in, so DFR would be interested in, as far as you know at this point, participating in a working group to sort out some of the issues that we hear from providers and from insurance companies and everybody else. Yeah. And also who bears regulatory responsibility, what role different stakeholders play in that process. Exactly. It does get confusing, frankly. And then when you have folks going in to the Green Mountain Care Board looking for affirmation of the rate and yet the whole analysis isn't there. Kind of tough. Yep. Any other questions? I'm sorry. Will you get back to us? I will. That's great. Thank you very much. Thank you. So we have, I don't know, Steve Howard is here and then we've got HR, Beth and Clark are both here. And so Steve, do you want to come in and share your thoughts? Sure. Thank you for being here. Thank you for having me. The record is Steve Howard. I'm the Executive Director of the Vermont State Employees Association. And I take it you don't want my expertise on ACOs. So I'll go right to the study section. I'm an expert on studying, although I didn't do much of it in my career. I have learned in the last few months more than I ever thought I would about an ACO. I think the BSEA, while we support studies and we do think there is a need for additional study of the ACOs, the ACO model in Vermont. I will say that our relationship with the administration through the Benefits Advisory Committee, which is a contractual committee that brings all the parties together, has been one of sort of mutual cooperation on this issue as we examined whether or not it made sense for state employees' lives to be attributed to the ACO. So if I look at the language, and I think it's pretty much the same in this version, is what hasn't changed. I think one concern we would have is if you're going to do a study and we are not opposed to an additional study that it be somebody other than the Agency of Human Services that conducts the study, we would prefer that it be somebody completely independent of the state government and of the administration with expertise in the ACO and the healthcare model. And mostly, we've done a great deal of research and had a number of months of conversations about this very issue and our Benefits Advisory Committee has advised the administration that we did not want to be part we did not want to be attributed to the ACO this year. And mostly it's because we want to see what happens, we want to see what the auditor's work finds. We just want to give it a little bit more time so this study would fit into that. We'd like it to be a little bit more independent. And this isn't mentioned in the bill, but I guess one of the things that our members, we just had a conference call about this last night because this is like a favorite subject to the SEA. One of the concerns we have isn't directly related to our healthcare plan. We feel fairly confident that at least in the next year there wouldn't be any negative impact and since we're not going to be attributed, there shouldn't be. There's definitely not going to be, but if there were to be attributed, we feel fairly confident that that would be okay. The VSEA member's biggest concern about the ACO in one care in particular is about privatization. And it's about what we see as the path being built to privatize the jobs that are in Diva and jobs that potentially administer the Medicaid program. I'm just going to raise that issue because it won't be considered this year or it won't be part of this bill, but next year I can guarantee you, I'll be back saying don't privatize Diva, don't privatize the jobs that administer the Medicaid program. We don't want one care to manage those programs. We want state employees to manage those programs. I just want to put that on the record because that is the biggest concern state employees have. Okay. So, I mean, that's a concern. Understanding of course that it would take a waiver and an act of the federal government in order to make that possible. And right now that is... It's not going to happen anytime soon, but it is a concern that they have. Anytime soon. Right. You're right. Okay. That's as much as I have to say. So, the question I have to ask of you is, I mean, you're saying let's wait and see what happens. And then, so I have a comment and then something to think about. If we wait to see what happens, one of the things that has to happen is that attributable lives reach scale for the program. And if it doesn't, it falls apart. So, we're going to catch 22 because the way we can reach scale in government is through government-sponsored programs. And if we... What we can't do, but what the insurance companies are really working very hard on, as is the ACO, is bringing lives in from a discipline. So, that is a huge issue. I just want you to know that having attributable lives, reaching scale is the only way that we're going to be able to validate the work that's going on. So, put that into the B in the bottom and we'll just maybe continue to talk about that. The other thing is, I don't know how, but maybe there's a way to think about some kind of a pilot program that encourages or has state employees involved attributing their lives. Short something that demonstrates that this isn't going to do what we all might think could work. I certainly understand that, Madam Chair, and I respect that. I think you'll appreciate that because the state health insurance plan has been so well managed and it's been really a cooperative relationship with the administration. Right, and for the last couple of years we haven't had a premium increase. That's probably not going to last much longer, but we are very concerned about anything that might upset that apple cart. We got it. Think about the things that, you know, achieving scale. Think about a pilot possible in the short term and then long term. Some of the concerns that you have about privatization, I think, are shared. So it's not something that we look forward to, at least from my perspective. I do think there is oversight and regulation, but there is not privatization in the future for me. We'll see what happens. We're glad to hear that. I had thought about that. I'm trying to figure out how you give Medicaid dollars to a private organization without going through some horrible. Our concern is when you have as much power as the ACO appears to have and UVM appears to have and you have a will to do that, there's usually a way to follow up. We're on a different page there because I don't see the ACO's power at all. They're a healthcare providing system. So we need to talk further about that. That's part of the education piece that's in the bill, the ACO's responsibility to start saying what they are and what they are not. So when you look at it, when we look at the ACO, I think people are looking at the hospitals having all this control. In reality, it's control of about $62 million out of billions of dollars. So it's not a big thing. So I won't go on my soapbox right now. No, I understand. We do think the permissions about administrative costs and salaries are helpful. That was initially when we started this discussion. One of the concerns was how much are salaries? It's not a huge amount of money, but we think those are positive additions. The biggest thing for us is to ensure that we reach scale and that our small community hospitals can maintain solvency so that we don't lose rural health care. That includes all the docs that are out there and all the DA's and SSAs. When you start thinking about what's before us in terms of health care over the next couple of months, we don't want to lose what we have. Absolutely. We agree there. Okay. Okay. So I'm sorry. No, that's all right. Thank you. Thank you very much. I like your testimony very much, but we're going to have to think about pilot maybe. I think it's something. I think it's something. We're always open to having a conversation with you about that. Okay, good. Thank you very much. Thank you. All right. Now, so Beth and Clark, if you both want to testify together. That'd be fantastic. Who wants to bring up a chair? I don't. Maybe someone could sacrifice a chair. Oh, I can't. It won't. It's all we've got to testify. I don't. I don't think that we don't want to. Thank you very much. Good morning. I'm Beth Fastigian, the commissioner of human resources for the state of Vermont. And Clark Collins is our deputy director of benefits and wellness for the state of Vermont. And I'm probably more familiar with him in this committee than you are with me. I've been around a while, but I believe this is my first time in this committee. Do you know everybody? I think so, yes. All right, good. I don't have to have you back. That's right. Yeah. Well, I probably not because this is not my area of expertise, but we have been, and it is Clark's area of expertise, but I mean my responsibility is managing the state employees health care program. We bid out our health care contracts. We manage the funds. We work with the VSEA very closely and see what the members want. So my job is really, it's managing that. Last year was the last year we put out all of our health care contracts out to bid and we had some very successful bidding. We're able to actually release, I would say save, but have a lot of future cost avoidance by rebidding those contracts, which we're really excited about. We reduced our OPEB, our retirement health care liability by over $200 million by rebidding those contracts and making some tweaks to those plans. So we're really actually proud of that and the work we've done. And as Steve mentioned from the VSEA, we've had pretty good success about not increasing the costs of our plan over the past couple of years. And as he did mention, increasing that this year, one of the things that we worry about is we increase costs at the same time. We joined, one care would be that employees would think it would be as a result of one care. Well, it really isn't. I mean, there is a natural rise health care costs. And with the lowering of the cost last year, that kind of gave us a jump down, but we still will go up. So I just want to say that, we don't expect that we will have zero increases for the ongoing period there. With respect to S290, obviously, we are not the administration experts on that. We would have a very small part on that, on the reporting part of that, working with Agency of Human Services and discussing employees' lives into the health care plan, what it's going to take to attribute employees' lives. In general, I'm not big on reports. I don't think this administration is big on reports, and we prefer not to have additional reports. That's always the goal, but for our part, and it would be manageable, and we are. As we have been exploring what it would mean for state employees to join, to attribute the state's lives to one care and all care model, we've really learned a lot and actually worked particularly with Ina Bacchus to kind of understand what it means and what you're talking about, Senator Lyons, about the importance of scale and the importance of attributing employee lives there. I think, and Steve mentioned a little bit the journey that we've been on for the past several months, really learning about one care and one care and both Blue Cross, Blue Shield, our insurance provider have been fantastic about providing information, making their employees available so that we really understand the model because what they came up with and how to attribute employees lives really enables us to join the model with really any very little fiduciary risk to our plan. But it's kind of confusing and complicated, especially when you're coming from a position of just kind of going off on your own. So I think it's taken a lot of time and research on behalf of both myself and other people in Department of Human Resources as well as members of the Benefits Advisory Committee at the VSEA to really understand what this would mean to attribute the lives to the plan. I'm at the point where I think that it's, I don't think there's a risk. I think employees could really benefit from it just having their lives get the benefit of the coordination of care. I want our employees to have that, but I also respect the work that the VSEA and the Benefits Advisory Committee is doing and they're recommending to wait a year and I would really like to honor that because I do value our relationship with them. This process has been very very helpful I think in building trust again between the union and the administration and we want to use that and build that to continue to talk about health care issues and other employee issues. So I think that's really where we are. The model that that Blue Cross Blue Shield and One Care have come up with and also the employees of both of those organizations and really getting down to the nitty-gritty and explaining how much money is actually at risk which is not a lot of money and it really seems like it would be a win-win for our employees like we win either way almost. So it was it's a very it works very well for us and it was I think pretty creative almost almost it was like it makes so much sense and then the other thing that we've done is we've we've worked with we've worked also with the VSEA and Blue Cross Blue Shield to try to get language to amend our contract so that would happen so I think we're also there. So we've really paved the way to have state employees join in the plan and we're really excited to be able to have employees experience the benefits of that. When I mention it just to employees that haven't been part of it and I said well what we'd really like to do is do this and they're like oh we don't we don't want to do that I can't even I have a hard time even getting a doctor's appointment so it's the whole health care system I think as you mentioned cool like the whole health care system they think it's just this one little piece of it and having a hard time finding a doctor and having all these other things or they don't like the hospital or they don't like this that's I think there's a big education piece and I think a better way to do it is when we go and have our employees be receptive to that rather than fighting it and having that negative additional negative hearing additional things publicly about it because I think it's really more of a lack of information of actual understanding about what it is and what it would mean so I think that that's kind of where we are at this point what I'm hearing you say is pretty much agreement with what we heard Steve Howard say well except if I was in my head and I didn't have to worry about what our employees thought I probably would have just thought it but it's really important for me in my job to think about our employees and our relationship with our employees so I think that that's where we are and I did want to respond to you about you had mentioned the pilot program one of the things that we are working into the contractual language with Blue Cross Blue Shield is the ability to back out so that if we do what you're doing in our lives it is not a permanent decision so sort of along those lines a pilot program doesn't necessarily have to be something official as much as contractually we are able to back out if we find that it's not working well for the plan okay so have you how far have you thought about having that contract in place I mean obviously negotiations are going on now right so it's ongoing I would say that we are near completion of a contractual amendment that would allow us to attribute our lives but as we've mentioned as Steve mentioned it appears that 2020 it might not happen in 2020 but in terms of going effective as soon as we can we should have the amendment pretty much hammered out so that we can go in once we're able to and so as I'm listening to this I think of I mentioned a cash 22 earlier and so it's the attributable attributable lives and then if we as Steve Howard's not here but he suggested well he wants to wait and see what the auditor says well if we don't have scale then we're going to fail ooh I like that that one but seriously so as Steve we're here because it's very simple to poke holes in a system if we don't allow for the system to go forward and I encourage you to work as assiduously as you can to with folks and we I think all of us will be trying to talk with others but the education piece is amazingly important I don't know whose shoulders that falls on is it the state is it the ACO I think that that's the I don't know who it is but I do know that the I really have to compliment the BSEA for digging in really trying to understand the model and how it work and how it would impact the plan and I think that's really when I heard what people are saying there was like there I think their biggest concerns about it have been have been met and it's just really it's just that extra plunge and that jump in the like like it's the hesitancy of change where it was where we as I think really where they are at this point and said give us some more time to think about it and so does that and I think we're going to really be there so I think that's what that's kind of what we heard around the table from members like they're very close it's still just the so and we're in year three right now putting together the behavioral piece of our waiver and then we're thinking about the next 2.0 waiver and if we don't reach scale we aren't having anything the whole system will fall apart we will be back at ground zero so I put that also into your heads and I will talk with Steve personally about the value of of moving ahead somehow a pilot program can you separate out primary care and their contract blah I'm not I'm not sure there's no way to do that anyway it's too late to think about that right now anyway but I understand your need to have more time I understand the cold feet issue or the cold water issue nobody wants to go swimming in March so okay we appreciate your coming in questions I would say any work that you're doing with your benefits advisory committee might want to meet more frequently so we've been generally it's a quarterly meeting Clark it was a quarterly meeting but during the process of evaluating the impact of the plan we were meeting almost weekly for a few months so good idea for me if the concern is privatization why don't we just take all this money and pass it through Diva that's the first that I've actually heard about privatization on this I haven't even talked about that with the benefits advisory committee I haven't heard that either they're just concerned about their health care plan that they're very they take a lot of pride in and they have a lot of ownership in it so that's where they that's kind of where they are but they seem to understand that it's probably the best way to move forward so not losing benefits is important yes but they don't they they understand what it is now but I don't think they understand the value of what it could be so I think that's really the education piece of what their what employees are really losing out in by not attributing their lives and I think that's what we have to work on really communicating alright any other questions thank you thanks for being here I think seriously thank you very much okay so committee think creatively I'm under concern of the idea that having an external audit by the auditor's office is going to solve all the problems when we haven't even met the complete scale and achieve the goals with a all pair and I like the art so is there a way for me to contact Anne Sue over at UTA are we going to get a we need to talk we're moving on to S 252 and we cannot live on without Jen so and we have S202 and we're going to take a five minute break I know on before we do that just very briefly on S202 I think Dora did you put did you put the letter that you just see from don't go away yet remand care board yes yes that should go up and then that's on 252 that indicates that remand care board has already put together planning for the inclusion of PT and chiropractic and I think that's it then on S 252 I don't know about you but I've had a lot of little emails oh yes and I I got a book did everybody else get a book yes now I haven't got a book it's in your I came to my house you have one of your nights what is it it tells us all about new and inspiring regenerative yeah regenerative medicine so what I understand is that the word went out from testimony that we were covering things that the Food and Drug Administration doesn't cover and approve and that we didn't know what we were doing at all that has been implied and explicitly stated in my response I'm acting there but this is a disclosure we're not banning it so you did see my reply right my single paragraph reply I thought that and so we will not violate any state or federal laws or rules so Jen did has tried to identify disinterested objective information so that we can move forward in 252 I love the submission of the lawyers in Florida in Florida did you read that I stopped reading I stopped reading them not because I'm not interested it's because they're getting into complexity and scientific complexity for which I'm not qualified and that's I don't know if you saw my response we are late people and it doesn't mean that we make high priests out of the scientists and say well this guy has the credentials and he says this so we believe him but on the other hand we're not scientists I'm not going to enter into debate with these guys either I think what we need is some guidance as late people we do have a responsibility to be scientifically literate enough to understand the experts so I need a little bit of competent expert guidance on how to interpret all this and even going through Dr. Weiss's PowerPoint you've had to go through it several times and listen to it so that you become fluent I think that that was the education that was brought to us the key here is what is it that FDA does regulate and what is it that FDA does not regulate S202 Chiropractic PT and I just asked Dory to put the Green Mountain Care Board information up and that said that they have already gone through and included Chiropractic PT it's a refresh none none, there it is okay Jennifer Kirby, legislative council what are you looking for on this bill this is the bill that would require chiropractic and your amendment at least does a go therapy services in silver and bronze quality health benefit and reflective health plans silver and bronze level to have a co-payment that does not exceed 125% of the co-pay for primary care that's right and so the concern was that would take a lot of analysis to make this happen what we've heard is that the analysis would be in place I think this was included in the plan design for the plans that were approved by the Green Mountain Care Board but that doesn't limit it correct that doesn't but if we do this bill it would limit it for until we do it until you changed it or not that is okay that's where we are so we know where we are so we can come back to this for discussion and vote when Jen is probably in the room okay I don't want to keep her here and so then let's go to 252 alright and this is a new draft we've been talking about the pains that we've been under 3.1 3.2 3.2 okay and we've been hearing information that said that this bill is totally against goes against federal everything 252 so the last version you looked at would have amended the definition of stem cell product to include in addition to homologous use of minimally manipulated cell or tissue products also include full blood derivatives and blood components I think that's what you've heard the most concern about and whether those are things that require FDA approval in the first place so that would be struck in this new draft and then there's just a fixing a typo on page 2 and I think the rest of it is the same as the last so to clarify then FDA does not get approval for the use of full blood whether in this or that I'm not sure I can say that with any certainty I have to tell you I'm not an expert in this area and I don't know which of these types of products requires FDA approval I've been trying to find out um these are what is referred to as platelet root plasma I could call get a whole blood is everything plasma blood cells and all the proteins and everything else that's in the plasma so a whole blood is everything so if you have blood components then blood components are could be clotting factors hormones everything so this is like stem cell products stem cell tissues so it takes blood out of the whole discussion literally but both the red cross yeah we don't want them now we have to run upstairs so can I ask you this question before you leave is there um how can we find out I'm going to bring David Hurley down here how can we find out the answer to this kind of that's a great question thank you I appreciate it I think I've used on other issues like vaccinations I've used the Department of Health for expert but now there are people who will say well that you shouldn't because the Department of Health is part of the plot but one way or another you're going to be stuck FYI I did send a note out to the Department of Health before the break they didn't respond to me they said they were working on it but apparently they have responded to Jen so I don't know the answer so they didn't respond to me so now I'm going to have David Hurley come up because he might be able to give us shine some light if you mind I'll be great your staff person hi I'm David Hurley Executive Director of the Board of Medical Practice and so I don't know that I can provide you a medical answer to your question but I responded on behalf of the Commissioner of Health to Jen because he and David were very busy with all the other issues and the more I thought about it this really isn't a legal problem I'm a medical problem it's a legal issue and what occurred to me was we were going about this in the wrong way so the treatment well let me see if I can take a minute and explain my theory the treatments that we were trying to add back in here there's a concern that some promoters may be taking advantage of because they're being sold the reintroduction of their own blood as a stem cell treatment is really what it boils down to and I went online and looked at some of the marketing and it's you know it talks about taking somebody's blood and putting it through a centrifuge essentially and reintroducing it and it talks about you know getting your stem cells excited and so the concern is that patients, consumers are being sold what they think is stem cell treatment and there's this aura around stem cell treatment as being the next greatest thing in medicine and going to be able to cure all kinds of things that we can't cure now and so rather than you know what our concern really is is about I think people being given the impression that this is stem cell treatment when it's not and to me the problem was we're trying to you know clump this in with the definition of stem cell products we say you need to make this disclosure I think that what we need to do is leave the stem cell products you know on its own and you need to make the disclosure if you're selling people's stem cell products as it's defined there and we have a definition we can use and then have a second approach that says you know what no matter what you're doing if you are marketing a treatment and you're talking about stem cells and that there's going to be a benefit and you refer to stem cells you need to make the disclosure that it is not an FDA approved stem cell treatment and that stem cell treatments are required to be approved by the FDA so in other words just you know we're not saying you can't do this you can't sell people the idea of taking their own blood out and putting it back in you just need to let them know it's not a stem cell treatment if you're talking about stem cells when you're trying to sell them that because I was trying to figure out how is the stem cell it's not and to me the problem was is that people are calling the stem cells and then the law we're saying we're defining this as a stem cell treatment which is the last thing we want to do I was reading a thing on the horse doping scandal what that thing did to your blood started to sound an awful lot like some of the claims being made for the enriched blood you know the increased your endurance and I'm saying okay don't talk about it yeah I'm just I'm troubled by how skillfully pseudo science trains itself I guess I'm pretty much every month called climate news from the heritage the heritage foundation is not a scientific institute it's a political right wing they have a right to their right wing political newsletter but it poses as science it's got graphs and the authors have PhDs and you think you're looking at science you're looking at advertisements for the oil companies is what you're looking at and then I get scolded by constituents that I'm being dogmatic because I trust the established and I'm being arrogant I'm pretending to be a scientist of course I'm doing the exact opposite saying I'm not a policy maker and I need some scientific advice to make science-based policy so that's what I'm worried about with some of these yeah, stem cell is it's going to cure everything and if you're being led to think you're getting stem cell treatment and you're not then I think you need to know that so the language you need to have 20,000 the language that we have in front of us as 252 have you seen the latest language that crosses out and hold blood derivatives and blood components and leaves the definition as it is stem cell products that was there previously does that satisfy the concerns that you were expressing because it's only stem cell it gets part way there I think that we need to add in additional language that gets at a disclosure based on the representation of stem cells being involved with treatment and there's one other thing I really need to say about that is I did bring you know I was part of a working group that discussed this and Jill Abrams who's an assistant AG in the consumer protection office she was on that group and I shared this idea with her and I don't want to put words in Jill's mouth but her first impression was that you know it made sense but that it needed some scrutiny and I don't want to speak for the AG's office and I know that Charity Clark has been here testifying so I think that you know you need to look at obviously it is you know can you make that disclosure requirement based on the mention of stem cells but that's from my point of view is someone who's concerned about the legitimate and appropriate practice of medicine I think that that's a good way to get at it so go ahead just so in here where we talk about stem cell products has the same meaning as is that the definition that you are talking about or because stem cells has a definition and what we want to say is you're not that definition is what I understand what you just said no we're trying to do two things because some of the things they are representing is stem cell treatments and representing that don't you know they don't need FDA approval or whatever and so that I think that's an established federal definition that's out there and I don't have any issue with using that and taking that as one part of the approach but then there's this other classic things to the first part of the approach that accomplished that to say to them you can't be calling yourself stem cell if you don't need this I think get it and then in terms of the language for the other piece is that something that you can send along to us, to Jen I gave Jen can you copy that so we can look at it it's pretty informal and needs her magic touch I know I think she read it to me but it would be good to have to have to see it that would be great okay and then we'll have to talk when Jen is in the room we'll have to talk about how we want to proceed with that have we touched on the AG the AG's office the AG was triangulated with that so we need to have the AG back in on this as well what do you mean triangulated Department of Health Ledge Council AG and touch with one another that was the best okay thank you thank you so there we are I hesitate to say on 202 or 252 but I'll go to 252 I'm looking I think we're going to wait until we hear back from our Ledge Council and the AG's office and try to put something together on this okay okay so then let's put that one side we'll come back to that and we will look at 252 which is draft 3.2 discussion me too 202 202 that is the I've said before I have concerns about we could be looking at some major increases in costs other places that to in perpetuity say unless we change the law you're guaranteed this rib I'm not comfortable with doing that I think we've already put in law range you can't go any higher than 150 I think that we've got and we tend every one of these is a good cause and taken in isolation they're all good causes but somebody's got to sit down and balance though is chiropractic really more important if you've got to decide where you've got to make adjustments then primary care and a outbreak I just don't think that we're qualified I think we we are the care board has come across with their recommendation but that's for this year I think that's fine but I don't like give it to them take it away you don't like the long term I don't like I just think it's we've done this with another a number of things and people come in I'm starting to have sympathy for appropriations taking in isolation everything should be done well but it's a finite people don't like paying taxes so everything can't be paid it's finite choices have to be made and I just don't like our hands it wasn't really just when the call pay was more than the cost of the treatment but we fixed that and I'm just not I'm not comfortable with the time momentum is a very powerful force mm-hmm and once the thing is in yeah would you want a grandfather son said none of the things yeah because next year we'll be another one well unless there's a bill that's going to allow for comprehensive analysis and send it to a working group I mean S290 is starting to look at some of the rates stuff in its own way and if does the insulin bill have a analysis built into it I think that's what's going to be done there's a study of having the hospitals provided at their cost plus the 340B cost that's what's being added while I get passed over today but that one insulin the lack of insulin is life threatening mm-hmm the lack of chiropractic is well, PT can be PT causes people to be immobilized for the rest of their lives but I think that's what we've set up the Green Mountain Care Board for and every time we start and running them we tie their hands a little tight they don't set farms because this bill came forward and the board went ahead and did the work so if this bill were here would that have happened? I don't know so I'm you know I think we've worked hard on this and I think we've looked at it in the past and we're adding PT into the legislative decisions and it goes it drops it down from 150% to 125% compared to what is currently in legislation so it does change legislation and it moves it back down if we don't it'll stay up there no, it's at 125 it's been at 125 since we took action but it has a range it could go up this will limit that it will set it at 125 right next year it will go up no but maybe it needs to so we can bring down the cost of something else like primary care I have the no copays in primary care we're just doing this kind of mirror vision you know blinders on where this tunnel vision and not looking at all the other moving parts and I just think it's dangerous okay, so is there any other comments to be made I think they're coming to excellent sense to be honest it's hard for us to do that if we take things on isolation you know we've got the primary care bill we've got primary care no copays we've just did the insulin you know that's why the green amount of your horn is if we're going to do the job then save a lot of money and get rid of the green amount of care okay do they affect diva yeah, okay any other comments I've made the same speech it doesn't tell you just give us the essence okay the big choice is is healthcare a public function or a private sector function we've decided it's a private sector function you're driven by market forces market forces lead us into all sorts of places we don't want to be so they're the government which won't run healthcare access does manipulate the outside system so that it doesn't do the nasty things market forces want to do in other words we have a market system weighed down with liberal bills and whistles that work against market forces that drive the market system in the first place it's a crazy way to do it and my view is it can never work I get bored because my sense is it's going nowhere it can't go anywhere we can join the rest of the civilized world and do what all industrialized democracies are already doing and have this be a public function or we can just continue to spin our wheels and have studies so on this bill senator I'll vote for it I'll vote for the damn thing if it's the best deal we can get if it's the best deal we can have another whistle I don't feel that way any comments senator westman I it's more important for me to have an insulin in primary care than it is and I appreciate what they do and I don't feel real comfortable putting a box around just this I generally agree okay well if you've ever had a lower back trouble like I have I'm not saying it it isn't important if you don't have your insulin you're dead point for all take well what I have is we make this slower but they may erase something else somewhere I don't know where it is I don't need it where's it in we need alignment don't charge okay well we're going to put this one aside for now it sounds like it's not ready for prime time there go my emails enjoy enjoy your reading and we'll come back to 252 when we have Jen in the room we can't do that without her that's a big lift so tomorrow wait is Mark yeah Mark I'm right here son oh thank heavens thank you that's a tough act to follow there is at his physical therapy alright thank you for making yourself available I know that was a nippy tough question thank you for accommodating this guy so this is back back to the future of S290 that section 12 which includes a study the more recent study of S290 it's the same on both email I trust you have copies of my testimony yes we have we are electronic do you know everyone probably not so but it wouldn't hurt to go around go ahead you can watch it in accounting Rich Weston in accounting Chitty and Lias Chittin in accounting Dick McCormick Windsor so thank you for being here and we'll listen to your testimony thank you for the invitation to be here so my name is Mark Hage I'm the director of benefit programs at Vermont NEA some of you may also know that I am the administrator for the Vermont Education Health Initiative VHI I have been in that position since late 2001 but I am not testifying today on behalf of VHI I am speaking exclusively in my capacity as a staff member of Vermont NEA and my testimony will be limited to section 12 subsection A of S290 which as you know calls for a report to be generated under the auspices with participation by Vermont NEA and VSEA to explore relevant issues connected to the future attribution or not of state employee lives and public school employee lives to one care of Vermont and the all-payer model now Laura Soares who's a fellow member of the VHI management team has provided this committee with a statement from VHI explaining his reasons for why it deferred attributing school employee lives, active school employee lives to one care of Vermont in 2020 and contrary to a Vermont Digger report I have to clarify that unanimous support for that statement came from the VHI Board of Directors not Vermont NEA Vermont NEA at present does not yet have a position on one care of Vermont or the all-payer model it may choose to do so or adopt such a position in the future but at present the union believes that looking to VHI for guidance and direction in 2020 is the most appropriate course to determine if and when and under what terms active public school employees should be attributed to one care of Vermont respectfully we believe that the public school community will be better served by allowing VHI to continue undertaking its own rigorous analysis of one care of Vermont which has been authorized by our Board of Directors than the generation of a separate report which is called foreign S290 and let me elaborate on that position if school employees were attributed or not to one care of Vermont next year they would continue to have access to the same health care plans the same Rx formularies and pharmacies and the same doctors and other health care professionals in the blue cross blue shield of Vermont medical network so when it comes to school employees access to care their experience as patients and their evaluation of the relative value of their health care benefits those are three areas of inquiry that are cited in section 12 of S290 those do not hinge definitively at present on the question of ACO attribution because again they're linked to VHI's benefit plans and blue cross blue shield of Vermont's medical networks in fact I suspect that most patients today have no idea if they are attributed to the ACO now they do get letters that is right now it's true it's true that good care coordination facilitated by a team of doctors who are attributed to one care of Vermont would enhance the medical experience of the patient and conceivably increase the value of health insurance in their minds the same would be true if they got good care coordination outside the ACO so in either scenario we wouldn't need an outside study to conclude that excellent care coordination is over the end that is certainly a point I will never contest nor does Vermont in the A. now when it comes to health outcomes I don't see how an AHS facilitated report one that would be released if I recall correctly in mid October of this year would predict or assess how health outcomes in the future for better or worse would be affected by the attribution of school employee lives to the ACO based on the timing of the Green Mountain Care Board's annual quality review of the ACO it's my understanding that the 2019 quality results will not be in the public demand until at least October when the proposed report an S290 must be completed in fact last night I visited the Green Mountain Care Board website and was reminded that a very long and complicated report on the cost of quality metrics of the 2018 ACO performance was dated November 20th of 2019 so the 2019 results are not going to be available to us until the report called for an S290 needs to be released so this means producing the report would be limited as we are now the most recent history of the ACO's quality results now studying the work of the ACO and health outcomes also referenced in S290 is admittedly complicated there's an excellent analysis posted on Green Mountain Care Board's website by the independent health consultant Julie Wasserman which has looked at the cost and quality performance of the ACO over several years it raised or deepened for me a number of questions so for example why did one care's 2018 Medicaid requirement score show a decline from 2017 in 7 of 10 measures including in too high cost areas, diabetes, malitis and hypertension why did it's 2018 Medicare score of 82.4% decline from 87.9% in 2017 which was itself a dramatic drop from 2016 score of 96.88% now with its commercial population one care's 2018 quality score of 86.12% was a significant improvement over the prior year 73.07% however one care had declines from 2017 with that group in two critical population health measures diabetes and hypertension plus in its hospital re-admission rate so why would there be declines in these areas as well I also learned in a letter last December from Mike Fisher at the office of the health care avid to Kevin Mullen who is the chair of the Greenmont Care Board that only 2% of one care Vermont's attributed patients in Blue Cross Blue Shield Vermont's commercial population who are deemed to be of high or very high risk are receiving care manager why are these percentages low especially given that commercial lives have been attributed to one care Vermont since 2014 now the reason I raise these issues is not to indict one care Vermont but over the course of 2020 there is a question of attribution cost and quality and as Vermont NEA grapples with it as well I have committed myself on behalf of the union school employees on school boards and in my capacity as a trust administrator to investigate thoroughly and pursue answers to these questions and more putting my and Vermont NEA's energies into this endeavor which involves drawing data from multiple sources and engaging in conversations with one care Vermont and others about how the attribution of lives and risk sharing will improve access to and the quality of care for school employees will be more productive and targeted than putting those efforts to the production of an outside report I also want to caution us as we move forward with our discussion about one care Vermont to not confuse the process of ACO attribution and how we pay for doctors with systemic reforms that are needed and how we pay doctors to not confuse those two things with systemic reforms that are needed to address the root causes of the worsening affordability crisis in healthcare such reforms include budgeting rationally for what we pay for healthcare treatments and pharmaceutical products and lowering what we are charged in the process to name a few the ACO aspires to lower the rate of rising medical inflation for worthy goal and to keep it at no more than 3.5% annually if it succeeds it will mean that a healthcare system that is unaffordable now will be minimally 3.5% more unaffordable next year and in future years I would also be remiss if I did not say something about the dire situation we are facing with the cost of prescription medications and excuse the bluntness or crudity of how I'm about to say but those prices are killing us and they're killing everybody in the private and public sector in fact I have been very impressed recently and told him so by very pointed comments the CEO of Blue Cross Blue Shield of Vermont Don George has made about that situation essentially one out of every five premium dollars is not directed to pay for prescription costs that's true for v-hine approximately and it's true for Blue Cross Blue Shield what the business as I understand it and just to sort of ground you every month of specialty medications today for Vermont school employees and their families is $5100 so specialty medications the monthly average price for generics is $23 now specialty medications are low volume high cost drugs often administered intravenously or by injection that treats serious chronic conditions like hepatitis C rheumatoid arthritis, cancer, MS, HLV and more these drugs account for more than 20% of V-high spending on prescriptions but only 2% of our subscribers take them right now somewhere between 85% and 85% of our members their prescriptions are filled by generics on an annual basis that accounts for just 20% of our spending so the trend that's unfolding with specialty medications is also unfolding nationally we've been told by our independent consultants as well as in fact by a very fine team of Blue Cross Blue Shield in Vermont that if nothing is done in the regulatory environment we are likely going to see those specialty medications in high cost low volume accounting for 60% of our drugs spend in just a matter of a few years now this is a big reason why Vermont NE supports S246 to establish a state based prescription drug affordability board under the direction of the Green Mountain Care Board Maryland took this step last year as I'm sure you know, Maine followed suit with a similar model school boards and school employees and all Vermonters, all employers public and private need extensive regulatory relief from the predatory business practices and greed of big pharma and we believe S246 is a very important step in the right direction everything we can do as a state to lower healthcare prices for school boards and school employees and for all employers and their workers in the public and private sector must be done and it's my hope someday the federal government will step in and do its part as well but S246 is certainly the step in the right direction and if you deem it appropriate we would certainly welcome inclusion so just to close, returning to the bill before you respectfully section 12 subsection A of S290 Vermon and EA for the reasons I've cited does not support an AHS report about one care Vermont and the attribution of school employee lives to the ACO, we believe the high can serve us very well in that capacity thank you for your patience and your time good, you've actually stepped outside of the section as well but we're very appreciative of the information you've brought us we are aware of the issues that have been discussed out there in the real world regarding the failure of the ACO and understanding that that failure is the result of not is it a failure? there are also explanations for it and I hope that you will go and look at some of the work therefore the agency and others have done in response to the criticisms that have been made knowing that the key for success for our waiver for the all payer waiver is having a scale of attribution there's nothing we can do about that in this room with the exception of public employees so we are not saying that all of our public employees will become part of the all payer program but we are a model but we are asking that it be assessed and I'm glad that you're doing that yes ma'am the issue around AHS study versus another you don't want to work with the rest of the group or wouldn't it make sense to have everybody in the same room rather than reinventing I think our focus behind particular and my focus as the union voice in that process can be more targeted and as extensive as it needs to be by working through that vein I speak to my union colleagues at VSEA we're not strangers to each other on these issues and if I deem it necessary and if they deem it necessary to speak to me we will certainly reach out to each other I presume in fact I would I'm calling for the investigation by VEI investigation is too strong a word our further analysis and study of one care Vermont to be as full-blown and deep and multi perspective as possible I've spent the last several months trying to catch up to what OCV is, what it has done understanding into genesis reading reports that sometimes feel way above my pay scale also talking to some really smart people who have been involved in healthcare or involved in ACO work for some time and I want to deepen that process and I think I can speak for my colleagues at VEI they want the same thing so and just a couple other things one to let you know that right now healthcare reform in the state of Vermont is the ACO and all care model that is healthcare reform so we have a choice to make it successful and to solve the problems that are embedded or to start over and we've been working hard in this room to try to find the problems and solve them so and I encourage you to look at it in that way S246 is a bill that we have looked at and we've made some decisions about prescription drugs and we'll probably have a section in the bill on prescription drugs that we'll be looking at transparency of pricing which I think is exactly what we all are trying to figure out so thank you this is good we've got questions did we get an answer for live performance belt? we did I'm looking I know part of it was scale yeah if you look at the populations can you give your name to the members? Elena Bear thank you okay well please we've got Medicare and Medicaid being the primary right and we have the secret people and right so it's tough I mean right now the folks who are there we have blueprint people that folks and Medicaid folks who are costly and do you want to say anything more about the no I mean I think that's precisely it's very difficult to look at effects when you're actually changing the population over time so what we're trying to do is create a methodology for looking at your comparisons which we just don't have the data yet but once we have the trends we have two years of the same people you can kind of see what the effect is of our we've had the pleasure I'd call it that listening to you present a Green Mountain Care where Elena is very thorough and the only thing I would say and clearly you're in a different world than I am when it comes to data but there is data going back to 2014 so when we look at the Green Mountain Care excuse me when we look at OCD on Care for Mana we're looking at over multiple years in terms of assessing at this point performance and both cost and quality but not the all payer all players in 2015 2016 we've got a five year window the cost share begins in 2017 with Medicaid but there were commercial lives in one Care for Mana all the points out is look at we're in a transitional time and so it's trying to back to the horse that's actually a really good way of putting it's a good way of putting is we're trying to we're trying to catch up too and our catch up process, our analysis process continued conversations with Elena and her colleagues all of that I assure you will be part of our work at V High and in Vermont in the game have you had an opportunity to visit at one Care for Mana I have met as at my V High colleagues with representatives at one Care for Mana my suggestion is to take a group up there and listen and see what folks have to say have an open meeting we did that, we had an open meeting we had others in the room it is very helpful it doesn't quell all the doubts but what it does do is it brings you up to where they are and what their work is on the other side of that with folks in Diva and this is why we said AHS because if we're going to have six different groups doing the same thing it slows everybody down or makes it more complex so I'm just suggesting think about how you might want to work again thank you anything else there's a great three stooches routine people are girly is tasked with closing a leak at the end of a pipe so he puts another length of pipe on and it's still leaking so it puts on a T now he has two leaks and it becomes more and more more complexity he ends up with about 500 leaks it has never occurred to him that it moves the end of the pipe once you screw something up everything you do to make it better makes it worse I think that's what we're doing but don't care no now we're not saying we're going to make it better another length of pipe we're going right to ground zero okay anything else any other questions you've been very thoughtful in your response and we greatly appreciate it thank you alright so we will we are finished unless someone has other comments okay so at four o'clock we're in room 11 and the goal is education petrification that'll be recorded yeah yeah we're finished