 Okay, we're back, this is the House Healthcare Committee. It's about 10, 15. We've taken a short break for ourselves and our witnesses. And we're now returning to continue to hear from and ask questions to Ina Bakas, Director of Healthcare Reform, about the all payer model and health issues at the federal level. So before we left, I think there were several other questions that folks had and Ina had not gotten a chance to finish her presentation, but again, I had warned her ahead of time that this is important for us to be able to ask lots of questions and likely we'll be doing this again because there are more questions and probably fit with our timeframe. So I think I see Representative Goldman has a hand and so I'll turn to Representative Goldman and then we'll see where we are and see if Ina has more to present and I'm sure there'll be more questions. So Representative Goldman. Thank you Ina for putting up with all these questions, it's hard. It's so complex, right? I was just looking at slide seven, I guess, it was one of the last slides you had up and then you were talking about the third year in a row and the contrast between fee for service as opposed to, I guess, paid prospectively is the language. And if I was wondering if you had any correlated outcomes for patients in those populations? I do have another slide to share about the quality observations that have been made in the Medicaid program with the ACO contract and Medicaid has the longest contract in this particular value-based payment. And so I can share my screen again and share that information with you. And so the next slide here, I have some information to share about program observations, including, or I think I do, maybe I don't. There have been incremental improvements in quality performance during this period. So there has been movement in the right direction during the same period on the quality metrics that are included in the contract between DIVA and OneCare Vermont and those quality metrics are related to the population health outcomes that the all payer model is seeking to influence, which do include reducing deaths due to suicide and drug overdose, increasing access to primary care and reducing the prevalence and morbidity of chronic disease. So I'm not suggesting that through this payment model and contract relationship that those high level goals have been addressed. I am suggesting that services and healthcare services that would contribute to those goals that we have seen incremental quality performance in those areas. We do have a quality model framework that the quality framework for the all payer model as well as the performance in the Medicaid quality program in particular that we have very versed expertise in the Department of Health Access. And if you wanted to do a deeper dive into that and look specifically at those quality outcomes that have been incrementally improving and to understand how they relate to the high level population health goals, we would be happy. I would be happy to arrange that presentation for you. It's certainly worth some time on a deeper dive and with my colleagues that have a more depth in that area. I just wanna comment if I may. In that, I think the financial piece is really important but I really wanna see it coupled with quality outcomes because what's the point if we don't have improvement in population health? So that's sort of an important piece. So whenever that makes sense, that would be great. Great, and I agree with you. So I'm gonna, my own set of questions I'd rare to ask as well, but I'm gonna turn to again, perhaps I don't know who was on first here. So the three of you probably do, so go for it. I'm last. On the current queue. Okay, does that mean Alyssa's first? Oh, go quickly. Just on your last slide, I just wanna clarify something. For the third year in a row, ACO participating providers who were paid prospectively. What providers and what provider type are we talking about? Who's paid prospectively currently? That's a mix of providers and provider types when OneCare talks with you next, I think they can tell you exactly the detail on that. Hospitals have been receiving fixed perspective payments. And then I would, again, I don't wanna speak on behalf of OneCare, but there is also the primary care practices that have been receiving the comprehensive, participating in the comprehensive primary care payment. I mean, I'm a little alarmed by that because it's put in here as if it's a good thing, but we know that when you spend more on primary care, you actually save in the system and spending, if a provider who's, a primary care provider who's spending less than expected, that's not a good thing. These results are. Patients are not getting enough care. These results are aggregated results for the Medicaid program. And I don't believe that they speak to primary care specifically. I would invite some, again, some more in-depth look at this, but this is the whole of those providers that were reimbursed differently than fee for service. And so in aggregate, at the end of the day, there was less spending than expected spent on the services within their control, and that less may be in services that are not primary care at all. It may be a different set of services entirely. Okay, I'll save my question then, I guess, for OneCare. Thank you. Okay. Representative Peterson. Thank you. The same slide. The second bullet, I'm gonna speak to just what Alyssa spoke to, kind of. When I see the results of that, again, I don't know whether to use alarming to use that word, but I'm wondering if they're spending less on services because they are making less. I wonder how are we keeping our healthcare providers happy in this state as far as what they can earn based on, I mean, let's face it, you know, to be a physician or even a physician's assistant, these folks have spent a lot of time, effort, sweat, pain, suffering and everything to get to where they are. And, you know, I think 99% of them are doing it because they call to do it, but there is the expectation you're gonna make a pretty good living. Are we, how does their income under our plan compare with the fee for service model that they've worked under before? Is there any comparison at all? I don't know. I think for each individual participating provider that could look like a different, that picture could look differently depending on a myriad of factors, the payer mix, the number of their patients that are participating, that are attributed to the ACO. There's a lot of factors there in terms of the overall financial picture. What I can speak to is again, going back to that slide that demonstrates the scale of participation in the Medicaid model. I do think that providers who have a relationship with Medicaid are choosing to be reimbursed in this fashion rather than the traditional fee for service because it is advantageous for them. It provides predictability. It provides stability. They can plan and work within a budget and they understand how much money they're going to get versus in fee for service, certainly, each additional service is rewarded and then there are also times where fee for service patterns of utilization change. People do not, the demand for care may shift in a significant way and dollars that you anticipated and relied on to make your budget are not available. And a great example of this is what happened in the early months of the pandemic when the healthcare system was shut down and not able to offer elective services, where there was choice involved, so non-emergency services, the healthcare system wasn't offering those. Those providers that had this fixed perspective payment that were being paid upfront at the beginning of each month, regardless of how many people walk through their door, those providers enjoyed more stability with this Medicaid payment arrangement during that very disruptive time. I mean, that's kind of the, that's probably the best example of how a fixed model can influence the stability of a provider's business, but there are other instances of that, that happen at a lesser degree pretty consistently. And I think that providers have elected to participate in the Medicaid program because they prefer the stability to the uncertainty that is also a part of a fee for service delivery model. So with that in mind, so I can somehow understand this, this would be like an employee at a company being salaried versus an employee at a company working a piece labor by the job. Is that fair to say that under our system, we're salaried, so you're going to get a set salary based on all these factors you crunch together versus somebody who gets so much for a service they perform? I think that that's a very, Okay. Very fair analogy, yes. Yes. Okay, okay. All right, thank you. Representative, don't you represent for us? So I want to go back to the question of quality measures where I think you said, we're showing, we're moving in the right direction, some positive indicators there. But I think we need to distinguish from what I'm hearing the difference between process indicators and outcome indicators because our outcome indicator on suicide and drug overdose, I mean, we're having this really significant spike in drug overdose and we have a higher than average suicide rate that's not improving. So we're not seeing outcome improvements. You're saying, I think you're saying they're process indicators and I think we had a bit of a conversation maybe a few years ago about whether those process indicators or progress are robust enough when we say we've made progress. And the example that I know of is, after somebody in a mental health crisis goes to an emergency department, we say it's good you've met the quality standard if the person gets a follow-up visit within 30 days after being in the emergency room with a crisis, which it seems like if we really wanna reduce suicide rate, we want that to be two days. So I mean, I feel like we still have a real disconnect there and that we shouldn't leave an impression that when you say progress, you're indicating on these process measures like 30 days after the emergency department getting a follow-up rather than saying we're making any progress on the outcome targets of the all payer model. Am I right? There's a mix of measures within the quality framework. I am differentiating between the measures that are at the ACO payer contract level and the measures that are actually not at the ACO level at all that are the statewide population health outcomes which in the agreement, it is the state of Vermont accountable to progress on those metrics rather than- Those are the ones we're not meeting at all as opposed to the ACO contracts there which are like the 30 day after and they're making progress on meeting. Is that correct? I hesitate on the not meeting the high level at all because I haven't looked, I would encourage you to get the most current assessment of where we are on the high level because I don't know that that's the case that we're not meeting the high level at all. I do know and agree that we are experiencing with respect to drug overdose and suicide, a lot of challenges. I don't dispute that at all but there's the prevalence and morbidity of chronic diseases also measure as well as access to primary care. Right, so we might be making progress on some of them but certainly on that global health outcome we know we're not making progress because the numbers are going way up. So I'm gonna step in here and ask as well and I think this is an example of how does this, how does entering into an agreement with stated goals, et cetera, get impacted by extraordinary circumstance? We are in the midst of what has to be the most extraordinary disruption of our personal healthcare systems as well as our system of healthcare in the state of Vermont. And I think that those are, I can remember prior to ever thinking there was a pandemic on the horizon, these questions being asked, what if something highly disruptive happens? How do we measure where we are? And I think, I mean, clearly we're there and maybe just speaking to that briefly would be helpful. I think that when we were negotiating the disagreement, we did name potential of if there were a pandemic and I feel chagrin now to say that we said, well, that's not gonna happen. And now we know better. And so when we evaluate this model, especially with smack dab in the middle of it, a global health pandemic, that is going to be taken into consideration that how people would usually access care was disrupted with regard to the healthcare system. We did and have seen an incredible innovation with telehealth, but it does not meet all needs. And then of course, just how our social fabric is changed and the isolation that we are experiencing in trying to stay safe certainly has an impact here that is one that the healthcare system, an ACO or otherwise alone is not within this agreement expected to be able to address in this moment. So I think it just raises just the broad question of like can we proceed with really evaluating this as a model given the level of disruption we have experienced and is the federal government prepared to continue to or does it make sense for us to continue to try to move forward and use this as a model evaluation? I mean, I just think that question needs to be asked. Well, I think it's certainly fair that the model can be in and is being evaluated by independent evaluators that are contracted with the federal government. It is being actively evaluated by an independent group and that evaluation is going to take into consideration these particular and incredibly unprecedented circumstances. I also think again, we can see clearly what appears to be working within the model and what appears not to be working and that's why we suggested we didn't suggest we created an improvement plan that contains within it recommendations to improve throughout the remainder of this performance period and some of those recommendations have been fully implemented and have shown an impact such as having a hospital participate a hospital in it that has not been able to participate up until this point with the Medicare program now participating in the model. That is an impact of carrying out a recommendation in the improvement plan. So I think there's different types of evaluation that can happen. There's the technical independent evaluation and that work that will determine whether the model generates savings and improves quality relative to its established goals that probably is going to make some adjustments relative to those goals to acknowledge, like I said, the circumstances of this global health pandemic and then there's what we can say as the real-time continuous improvement that we are actively engaged in as we look to complete this performance period having been interrupted by a very significant challenge to the state and all of not just this healthcare system but to all of us and that we can step into the final year of this state and federal contract continuing to promote those changes that we can observe as being necessary to better performance. So thank you. I'm gonna turn to Representative Houghton who hasn't weighed in previously with a question and then we'll hear the other questions as well. And I'm also hoping that we, given the time that we have that the improvement requirement, I'm stumbling over the right terminology here but I think there may be, so make sure that we have some sense of that before we finish. So Representative Houghton. Thank you, Chair. And actually that was gonna be one of my questions. We seem to be short on time with Ina this morning and so I was hoping to also get to the reboot and then specifically my question is I'd like to understand that the timeline and the players involved with negotiating a new contract as we are closing in on the end of our session, I wanna make sure we're clear as to next steps. I can answer the question about timeline with respect to a proposal for a subsequent agreement. I can do that first and then turn to the improvement plan and the recommendations therein. We are required via the agreement for Medicare's participation in this model. We are required to submit a proposal for a potential subsequent agreement at the end of performance year four, which is where we are now and the end of this year will be December of 2021. That's a proposal. And so I think of that as a starting place for discussions with CMMI about what a next agreement could look like. When we negotiated the agreement, originally we submitted what we called a term sheet. After submitting that term sheet, we went back and forth with our partners at CMMI I believe we submitted the term for nearly a year from the official submission of the term sheet. We went back and forth for nearly a year to shape what ultimately would be the agreement. And during that time, we provided testimony, I believe to this committee as well as to others in the legislative body to update and describe what it was that we were working on and developing at that time. So we would absolutely be providing for that same transparency into the process mirroring how we did so previously. Before we submit a proposal, however, as I said earlier on, we do want to continue to gather information about what is working, what is not working, what we should be addressing that we're not addressing in a relationship with Medicare. One of those examples is that Medicare does not pay for the delivery of mental health and substance use disorder services by a licensed clinician. It only pays for a master's level clinician delivery of services given what we are experiencing with the increase in substance use disorder with mental health concerns with deaths due to drug overdose in our state. I believe we're very warranted in looking to Medicare to partner with us in that way. That's an example of something that we could be thinking about for a future agreement. And that's what we want to be collecting information about as we reflect on what we've accomplished in these last four years. And certainly reflect on what has been changed because of this global health pandemic that we need to be thinking differently about in the future. So prior to the submission of the proposal, which will be as required at the end of this year, we will engage with the public, we will engage also with the payer and provider stakeholders that are participating in this model, not to mention One Care Vermont, ACO, any other ACOs that would become active in the state. We will engage in that process of soliciting feedback and developing a proposal with that feedback, taking that feedback into consideration. That process, again, spring, summertime, which I always, I guess it becomes summer in June. Or today after the rain, everything greens up. Can I just have a couple of quick follow-up questions? So you keep saying we, who is the primary for this process? The agency of human services is through the agency of human services as a signatory on the agreement as well as Green Mountain, we would be working with the Green Mountain Care Board as they are co-signatories on the agreement. The agency of human services is definitely committed to ensuring that this engagement process happens to inform this subsequent proposal. That's what I mean by the we. I said a lot of words there, but I think the signatory is on the agreement. And then one last question. So a proposal in December 31st, 2021, when does a final agreement have to be signed to ensure we don't lapse if we choose to move forward with another agreement? A year from then. A year from then, thank you. Okay. Again, I wanna make certain that we have and we have probably 10 minutes at this point before we wanna switch gears. I wanna make sure that we have a picture of what the improvement plan expectations were that were set forth by the community. We've been through some of this before, but I think it's be helpful to at least review it in anticipation of our further testimony from one care as well. The plan has four categories of recommendations. They focus on the work between the state of Vermont and our federal partners to maximize our performance in the agreement and to address some aspects of the agreement that we can see clearly aren't working in our favor. Another category of recommendations are those that relate to how the Agency of Human Services prioritizes healthcare reform activities and organizes healthcare reform activities in the agency in service of those high level goals, certainly and as well to be aligned with the overall objectives of this reform. Excuse me, there are also recommendations that are regulatory in nature and directed more so at how the Green Mountain Care Board gathers information about the ACO and looks at its activities in light of value-based payments rather than fee-for-service payments. And finally, there's a category of recommendations that are directed at One Care Vermont because it is the only participating ACO and that are focused on how One Care Vermont strengthens its leadership strategy how One Care Vermont improves in its work as the convener and as the leader of a network of providers that is statewide and that is invested in continuous improvement in terms of healthcare quality and value. So I can move pretty quickly through these. I'll move along now. Yeah, I think we should move quickly through them. And if it's okay with you, I can move so quickly as to kind of skip over things that I've already talked about with you. We do think it's important that we work with CMS to revise the scale targets in this agreement because there are some aspects of the scale targets that through implementation we realize are absolutely not realistic. There are persons that we're accountable to have attributed to an alternative payment model. It cannot be attributed to an alternative payment model and those should be removed from the denominator. That's a Vermonter, for instance, who has a primary care provider and gets the preponderance of care out of state. So Florida, for instance. We, I talked to you about the reduction of the risk corridor thresholds for 2021. We also, I talked to you already about the guidance that we'd like to see for the critical access hospitals. I should say that this category of recommendations does involve, excuse me, collaboration with CMS. And we do have a relatively new federal administration. That federal administration is also very busy addressing the global health pandemic. Leadership, leadership, new leadership is falling into place. And with new leadership falling into place, we can better have these conversations. It is taking, it takes time no matter what with the federal transition. I do think it is taking just a little bit more time but we are starting to see that leadership fall into place. It's very exciting that we'll be able to start talking with CMMI as represented by the leadership that the new administration has put in place. So that's very exciting. We also, I talked to you about this as well already. We're concentrating on how the Medicare payment mechanism can mirror the Medicaid payment mechanism. Providers have demonstrated that the Medicaid payment mechanism is appealing. The Medicare model is not as advanced in paying differently as Medicaid. And so we want to work with our federal partners to bring Medicare along into more alignment with Medicaid which is fully in the spirit of this agreement. The Medicare 2021 benchmark, the Green Mountain Care Board can talk to you more about this, but it was very important that that process be one that took the global health pandemic into consideration because it was absolutely a complete anomaly in terms of the experience. And so of healthcare during that time when it's continuing now, and that does influence how you set a budget appropriately. We also recommended that we collaborate with CMMI to encourage HRSA, the Health Resources and Services Administration to prioritize value-based payment for FQHCs. This is a longer term recommendation, as you can see here. Also something we're really excited about because I believe that there is real interest in FQHCs participating in value-based payment and in participating in and being able to be a part of that payment that is more fixed in nature, more predictable. This category is directed at the AHS, the Agency of Human Services and how we prioritize healthcare reform as well as how we organize our activities. One, with respect to commercial participation in this model, the recommendation seven talks about outreach into non-participating self-funded commercial groups. One of those large groups of commercial self-funded included includes the state employee plan. That's the state employee plan was not participating with OneCare Vermont. We recommended that it should participate with OneCare Vermont and it is now for this performance year. There is more work to do on outreaching to other large self-funded groups, but we have accomplished this recommendation regarding the state employee plan. That's another significant development in this model that we succeeded in seeing even during this global health pandemic. We also are prioritizing the integration of claims and clinical data in the health information exchange. This is important information that can be made available to providers, that can be made available to accountable care organizations in the state. That is critical for informing care delivery and a value-based design. Providers need to both be able to understand a clinical picture for those in their panels as well as a claims picture. That claims picture gives the providers the tools that they need to manage within the budget. And so to this end, the health information exchange work has been organized in the secretary's office and in the office of health reform in the agency, where I sit as the director of health reform and we are going to be integrating Medicaid claims data coming up this very soon. I'm not quite positive on the timeline. The Medicaid claims data this summer with commercial data prioritized immediately to follow or even in tandem for the HIE. We also are partnering with OneCare Vermont and OneCare may want to speak with you about this as they're waiting for their testimony at this point about the efficacy of the care navigator platform. This is the platform for providers to use to coordinate care and to share in care plans for shared patients, patients in common. We've heard a lot of feedback that this platform is not ideal for providers for a variety of reasons and we together with OneCare are looking at whether or not the platform is the most effective tool to use in terms of care coordination. We've also sought a lot of input from direct users, the delivery system users of this platform to understand why it is not working. And so you'll speak with OneCare again very soon here but I think we imagine that through their work and our work, we would soon be making a recommendation in light of care navigator. Because it is the objective of the state to move as much payment into value-based arrangements as possible, we suggested in recommendation 14 that AHS would explore whether or not provider participation in the blueprint and the receipt of payments within that model should be linked to a provider's participation in a value-based payment arrangement with an ACO. This is an area for exploration. I do note that there have been small increases in the Medicare program to fund the blueprint payments and those small additional increases are ones that were targeted for participants in the Medicare risk program. So we made the decision that a small increase for payments for providers should be associated with their participation in the risk model for Medicare. It's the risk model for Medicare that generates these small increases for the Medicare dollars that go to blueprint. And so it is in alignment with that avenue that providers who are taking risk and generating the increase in the payment by being at risk that those at risk providers are rewarded with that small increase. So I'm just aware of our time and I'm just concerned that we're going to, we're already going to be short on time. It's very clear all the way around. So let's see if we can find our way through this as briefly as possible because we're gonna turn to one care very, very shortly. I'll sum up, I think that I can sum up recommendations 15, 16 and 17 as being very pertinent to those high level population health outcomes that we are looking to achieve as both the state of Vermont and in collaboration with the system of care. These recommendations are in progress now and are important for being sure that we are in our own programs at the AHS ensuring that we are participating in and that we have created models of care for people with complex medical and social needs that are the most advantageous and that are directly influencing social benefits and determinants of health, mental health and substance use dependency. And I talk to you about the recommendation, I talk to you about our plan stakeholder engagement as well. I'll sum up the Green Mountain Care Board recommendations being in the aspect of the first being consistent with our objective to see more payments shift to fixed perspective payments. And that is very much the case for commercial payer participants as it is for Medicare. So we emphasize Medicare in the federal relationship. We need to work with commercial payers through both the Green Mountain Care Boards role as well as AHSs to be sure that commercial payer and one care contracts have fixed perspective payments. And additionally, we recommend and these recommendations were developed with the Green Mountain Care Board staff participation that the Green Mountain Care Board is looking through its regulatory processes about how one care is identifying opportunities for savings and how one care is connecting providers reimbursement in a way that is consistent with the quality outcomes of this model. And finally, the recommendations for one care do focus on how one care elevates data as a value added product for its network participants. And that connects to our thinking about what's available as data through the health information exchange and wanting to improve that data by linking claims and clinical data in the health information exchange. And it is our objective for social determinants of health data to follow in the health information exchange and in fact, to follow behind mental health and substance use dependency data as well. We also recommend that one care focus on how it can ease providers transitions into value-based payment and delivery system redesign. I apologize for the typo which I've seen before and seems to be like a ghost typo. This recommendation really does speak to that readiness for risk. So in terms of the participants in one care model and as well as it speaks to working within a model of continuous improvement, providing data and information so that providers can maximize their performance within a budget. We recommended one care identify and perfect its core business that it provide useful and actionable information and tools for participating providers and to improve how it packages data for providers. We did hear that the data that providers were receiving that providers felt that that data could be more applicable to their practices more timely, more actionable. We also recommended one care Vermont foster a culture of continuous improvement and innovation and learning through focusing on data as well as establishing systems for improvement and clearly tracking the results with its network and finally that one care improve in its transparency and responsiveness to partner requests for information. So we, I think if we can take down the screen I think that would be helpful right at this point. I'm acutely aware of how much we're trying to cover in a period of time that it is clearly not sufficient but it is an attempt to try to take next steps. I think at this point, I know there's questions and I know that we have Vicki Loner with us and we have again a limited period of time. My best judgment is at this point that we shift our attention to hearing from one care briefly and focusing what time we have on questions. It's clear that we'll want and need to come back to this. And so I just want to acknowledge the frustration of having more questions than time but I really do appreciate it. And I think it was valuable enough for you to field our questions early on because it's important. There are many, many, many more questions and stakeholders are raising questions both about the agreement, the Alpera model, ACA model agreement, as well as one care and it's part of our job to try to make opportunities for committee members to both get sufficient information and opportunity to ask questions. So I see this as the next step in that and not the last step in that. And I want to acknowledge that the Green Mountain Care Board, I don't know if there was a misunderstanding, I hope not, I'd seen them as a resource and not as a witness today, but apologies if there was a miscommunication there. And given our time, I'm going to suggest, well, I'm going to ask first committee, I'm going to turn to committee members. Shall we take a brief break or shall we just continue? What's, I'm trying to, I'm seeing nods and shakes. Let me ask the question, shall we take a brief break? Yes. I'm seeing very conflicted. Okay, we really have limited time. We will reschedule more time. I think we're going to take a stretch break. We're going to take a stretch break of only three minutes and then we're going to come back on screen and then we're going to hear from Vicki Loner. So I don't know if that maybe doesn't satisfy anybody, but that's what we're going to do.