 Good afternoon, everyone. Welcome to Greenbond Airport. First item on the agenda is the executive director's report, Susan Barrett. Yes, thanks, Mr. Chair. I just have a couple of reports that I wanted to announce, report submissions that I wanted to announce. We at the board have several legislative reports that we need to produce and submit to the legislature. So recently on December 1st, we submitted a social service integration report that was per Act 52, 2019. And that act was looking at relating, that act was related to social service integration within Vermont's healthcare system. And that report is posted on our website. I'd encourage folks, especially very relevant to the ACO, because it looked at the integration of social services into the ACO. And I don't like to call up too many people personally, but I know Melissa Miles, our deputy director of ACO and all-payer model, as well as Sarah Tukesbury did a lot of work on that report. So thank you. On January 1st, we will be submitting the impact of prescription drug costs on health insurance premiums report. This is the second year we're doing this. Our last year's report is posted on our website. And of course, this year's report will be posted as well. And then January 15th seems to be the day that the legislature asked for reports from several different agencies. So I'll just quickly run through these. So we'll be submitting the primary care spend report. We're doing that work in conjunction with our partners at DEVA. We will also be submitting the cost shift report that's embedded in our annual report. The rural health task services will be submitting their report, right Robin? Yes. I actually hope we might split it a little early, but we'll see. Awesome, we'll see. That's awesome. And then of course our annual report from the Green Matten Care Board to the legislature. And again, embedded in that annual report is information on the expenditure analysis. So I wanted to just make sure our folks in the public and the board is very well aware of these reports and our staff. But please do take some time to check these out on our website if you are interested. That is all I have to report, Mr. Chair. Thank you, Susan. Next item on the agenda for the minutes of Wednesday, 12-11, is there a motion? So moved. Second. It's been moved and seconded to approve the minutes of Wednesday, December 11th, and on the additions, deletions or corrections. Is there any discussion? Seeing none, all those in favor signify by saying aye. Aye. Any opposed? Next on the agenda is the Bench Park Proposal, Sarah Lindberg. And Sarah Lindberg, I'm a Health Services Researcher. We're over the Green Matten Care Board. Yeah. So in the interest of trying to increase some clarity, I thought I'd just spend some time level setting about how this all works together before we get to the post vote. So I just wanted to point out that there are a lot of financial targets that we talk about. We're talking about all this stuff. So there's a difference between a financial target, between the ACO and a payer who's participating in the model, that's a very specific relationship, versus the targets that we have model-wide. So for the all-payer model, we have assessors on the targets. So for each payer, they're gonna have, for each year, a target. So Medicaid comes up with a target with one care. Glucose Bushield comes up with a target for one care. The Medicare benchmark is where the target is set between the ACO and Medicare for the year. So it's a very discrete part of this big machinery. And those are only, those are limited to people who are attributed to the ACO. So this is truly the population that they're taking care of. Versus the all-payer model is a much broader look at delivery system reform. So they have three main pillars of targets. One has to do with scale, which is the number of people who are participating in an ACO. And the model doesn't say there's only one. Theoretically, it could be more ACOs. So it's the number of people attributed to ACOs in Vermont, or Vermont residents attributed to ACOs. And those targets are for both the statewide or all-payer population, and also with a subset of just the Medicare beneficiaries. We also have some targets from Quality, which I'm pretty ignorant about. I know there's a lot, and I'm so grateful to people that are experts on that. But some of those are also for our statewide Vermont population, and some are limited just to those who are attributed to an ACO. Not one care, but an ACO participating in this model, of which one care is one. And then we have financial growth, which is the one that I talk to you the most often about. And we have two different targets there. There's the all-payer, which is how statewide, across Vermont, our expenditures are growing, and then just for the subset of the Medicare spend. And this has nothing to do with necessarily being attributed to an ACO. So they're very different ways that we are thinking about these targets. So these contracts also probably often have quality measures in them and maybe some reporting requirements. So there's other conditions in there besides financial targets. But that's gonna be different. How it's negotiated in most cases or arranged with ACO. So when we think about just the financial targets for this all-payer Vermont wide deal, for that statewide target, we think of our all-payer growth target, which is for the life of the agreement. And that's just saying our average growth between 2017 and 2020 today should be 3.5% or less. So that's our target today. At the end of the agreement, we're beholden to this growth until 2022. But we just need to see if we're on track so far. So that is our all-payer target. So what is our Vermont wide spending per person in 2017 compared to what it is in 2020? The reason we raise that to the third power is because it's three growth periods. No funny math there, 17 to 18, 18 to 19, 19 to 20. That gives you your average growth rate. And that target for when 2020 is over, which we won't have the results so close to the end of 2021, that number should be less than or equal to 3.5%. Medicare's a more complicated calculation, but I promise it's not too painful. Bear with me. So the Medicare growth is tied to these national projections. So every year Medicare says, we think nationally this is how much Medicare is gonna grow in the next year. And our target under the model is to be 0.2 percentage points below that. And again, it compounds over time. It's always the growth to date. So for the way that works is each year we compare the ACO Medicare PMPM in the current performance year to a reference population in the year before. And there's a really good reason why we can't compare the same people just mostly because of those death and end of life costs. So if we were gonna try and do the actual growth of the actual people, it would kind of be unfair to the ACO. So we wanna say given who is actually participating in ACOs, this is how we think that patients attributed to those providers are expected to grow. So we do that for three different years. So this next year will be how the ACO does at the end of 2020 and how that comparison group did in 2019 will be kind of stacked onto this. And right now at the end of 2020, we know our target for just that Medicare group should be less than or equal to 3.75%. So the numbers all kind of coalesce around the same place but we get there very different ways. So again, the Medicare benchmark is just that target between the ACO and a payer. And the way it works is we set a target which is represented by the green dotted line here. There's the ACO performance. If it's below that dotted line, that would be where the shared savings come in. If it were to exceed that dotted line, that would be a shared loss. So that's all it is. It's just a target for the expected spending by the ACO in the upcoming year. So right now we're trying to make that target for 2020. And because of the way, again, the model is written so that we have to do that for two different versions. One version is for people who are living with N-stain adrenal disease and then the rest of the Medicare beneficiaries. And that's because that N-stain adrenal disease population is very tiny but very expensive. So it's one way to help provide some protection for risk to the ACO or in just getting an ACO. And the way each of those we factor or calculate it we just try and figure out what we think the spending is for the current year. Multiply that by the number of people who will be attributed to the ACO for the upcoming year and apply a trend rate. And so the board's decision today is what trend rate we should use. And that decision point has to do with what we think growth is likely to be in projecting that forward, keeping in mind these statewide bigger goals that we have for the model. So our recommendation has not changed. We recommend that we use a trend rate of 3.5% for the non-ESRD population. We have a couple of placeholder numbers still here. We're still finalizing the estimated spending for the current year, but that should be pretty close to final, you think. And the number of aligned beneficiaries is coming from last year's benchmark. We're expecting to get those final numbers today for the number of people who actually will be attributed to the ACO for 2020. That trend rate, so that's your decision point and the projected per beneficiary or per member per month target for 2020. And we do something similar for the ESRD population. So again, estimated experience, the number of folks we think will be attributed to the ACO in 2020. And then our recommended trend rate of 2.9%. Why not 3.5? That has to do with the way that the targets more constrained are calculated. So that's the maximum allowable based on the data available to us. So that condition, again, is small and highly variable, presents more risk. So we would definitely advocate for using the maximum trend for that population. And then finally, our recommendation for including an advanced shared savings component. So don't mean to make that sound fancier than it is basically to help with cash flow and help support the work of the Blueprint for Health and the SASH program. What we Medicare has agreed to do is pay that money up front to the ACO so that they can have that money flow through to those programs. And then at the end of the year, that would factor into the performance. So if they save $10 million, they would only get a check for whatever to above that 8.4 million. So they're still on the hook, they're still accountable for that spend, but it kind of helps make sure that those programs are continuing to be supported. The number did go up a little bit, as I told you last week, that number is 8.4 million dollars and that just has to do with blueprint calculations. So the Blueprint for Health has a little bit of increased inflation and then the attribution numbers have evolved a little bit. So that's what we think that would need to be paid out for these programs. Again, this is a blueprint for health and SASH thing. Not all these folks are actually going to attribute to the ACO. It's a separate thing. The money is being supported and invested through the ACO, but it's not all ACO lives. So yeah, at the end of the day, that's what the math all boils down to. Again, the experience and perspective lives are still subject to change, but that should be in the ballpark of where we expect that final benchmark to land. So any questions I can address for you? Any questions from the board? Just a question on the slide on the left one. The three years coming up to less than 3.5%. When will we be able to get a pro forma of what this, you know, where we stand? Oh, sure. So for 2020, I generally don't like to say too much until we have at least six months in the books. So then I want at least three months of time for those claims to get paid. So that would be spending through June of 2020 with claims paid through September of 2020. And I get that extract around November of 2020. So it's pretty close to the end of the year. Yeah, and we're collaboratively trying to work to have more recent indicators, more timely indicators, but it's hard because you want it quick, you want it timely, but if it's not very informative, it's hard to want to make a decision based on that. But you can certainly get some early indicators and we get reporting along the way and we'll do a better job of presenting that quality to you guys so you can see where we're looking. And we certainly will have 19 members in our next presentation for you so we can start looking at that. And just one other question on that and we'll talk about the National Medicare Spending. Can you talk a little bit about how Vermont is starting to really guess the National Medicare Spending? Sure, so Vermont's Medicare Spending has steadily, consistently been quite a bit below national spending. The growth is a little bit bumpier. Smaller state kind of makes sense to be a little bit more volatility in those estimates, but the whole reason to my understanding that this kind of idea came up is that there was a year where Vermont had a huge growth rate compared to national and so there was this idea that we are a low spend but high growth state and how can we get ahead of that and bend that curve to be more in line with inflation. So I have not seen in the data available to me years where we've been much higher than national, we tend to be below or pretty close to it in the past couple of years, but every years I've found a new panel or something hard to predict. Yeah, that's a good answer. We're going to go a little bit below the National Medicare Spending. So we took a great, unwavering path. Yeah, yeah. Other questions from the board? Seeing none, I'll open it up to public comment. Is there a public comment? Seeing none, is there a motion? I believe that we approve the Medicare benchmark with a 3.5% non-ESRD trend rate and a 2.9% ESRD trend rate with $24 million in advanced shared savings for food-framed SAP programs. Okay, it's been moved and seconded to approve the benchmark with a 2.9 for ESRD, 3.5 for non-ESRD, and including the $8.4 million for SASH and the advanced shared savings. Did I adequately sum up that motion? I don't see SASH in here, but yes. SASH, okay, gotcha. Blueprint includes SASH. SASH doesn't necessarily include blueprint. Okay, any discussion? Seeing none, all those in favor, signify by saying aye. Aye. Any opposed? But the record shows unanimous vote. Okay, we're going to transition now to the ACO budget and then invite Elena, Melissa, and Marissa down. And we're going to be ready. Okay, I can go ahead and just kick us off. So I'm Elaine Verity. I'm director of value-based programs at ACO Revolution with Miriam, Melissa, Miles, and Marissa Nulman as from ACO Revolution. Today we'll be presenting our final recommendations based on last week's preliminary recommendations. We have fewer slides for you this week than last week. So since then we've received three public comments, one of which we received this morning, but we reviewed all of these public comments and where we saw merrily incorporated them into some last minute revision to those recommendations. We've also worked with our legal team in incorporating peer feedback based on last week and further conversation. And today we've, and I think part of that conversation is around how to best administer these recommendations in a very precise manner so we can follow the deliverables over time. So we might look a little bit different, but we've tried to note where exactly they tied to last week's presentation so the public can follow that. But there's no substantive content change. It's mostly just clarifications. So today we wanted to start with an FAQ. It seems that there's been a little bit of confusion existing in the public and other spaces as it relates to all their model in the ACO budget process. So our team is working to put together an FAQ document that we will eventually post to our website. But we wanted to take the time to go through a couple of these as it relates to the budget today. And if you missed last week, I just included a link here for anyone who doesn't. So our first FAQ will just start us off. So a lot of people ask questions about what the all-care model is and what the all-care model agreement is and what is one care's role in the all-care model. So we've laid out several different bullet points here and I think it might be just easiest for me to kind of run through them. So the all-care model is an agreement between Vermont and the federal government allowing the major healthcare payers to pay differently for healthcare by changing incentives to reward improved provider communication and patient outcomes over volume of services provided. In the agreement, the ACO is the vehicle to implement the all-care model and there may be multiple ACOs who could operate in Vermont to implement the all-care model. An ACO was adopted by CMMI as a vehicle to bring together a network of providers. It's basically a vehicle vehicle to bring together a network of providers. Some states have just healthcare providers, some states have social service providers involved. We have a team of care in our network in Vermont that come together to be accountable for the health of a population and to work toward the goals of the all-care model with the state. So an ACO, and in particular the ACO in Vermont works to reduce care and improve care and reduce costs by allowing providers to bring their money and resources together in four ways. So in Vermont, we are looking for population health investment dollars for providers to be able to transform the way that they provide care. They're also providing information which would be through data and analytics, care coordination and then innovation. So in Vermont, we are looking for ways that the ACO is encouraging innovation in care delivery to test out what could become best practices for Vermont's unique population. So as I mentioned, it is possible to have multiple ACOs in Vermont. We have one and that is healthcare. Okay, so as it relates to one care is our ACO in Vermont, their budget growth. So one care is for those 1.42 billion dollar budget. It reflects a 59% increase in total revenue over fiscal year 19. Does this budget growth imply an increase in cost to consumers in the state? Generally no. Most of this budget is existing healthcare spending just paid a different way. The increase in revenue is almost entirely explained by the increase in patients for which one care is now accountable. So this is 160,000 in 2019 and 250,000 in 2020. So this is a 56% increase in attributed lives. And to get precise, we would want to kind of look at which lives those are, because some lives are more expensive than others, but generally this is a direct reflection of a 59% increase. How's the green on the care board monitoring one care to ensure that their budget growth is reasonable? So we have this budget process, of course, where we analyze and kind of ask questions across how the dollars kind of link to the program as it relates to the goals of the state. But in addition, we generate recommendations that they, or we're doing this here, we have recommendation that one care should present on or before April 15th, their final attribution revised budget. So we can see how these things settle once those contracts are final. In addition, we carry forward recommendations from fiscal year 19, requiring one period submit quarterly financial statements. And we'll go through those in more detail as we progress through the rest of this presentation. The $13.1 million in DSR funding, I think there's been some confusion about what this is and isn't. Part of this is just the word to the DSR delivery system reform. There's DSR funding and then there's still delivery system reform efforts. So I think we have to be clear because unfortunately these things are commingled. The DSR funding is very specific to a grant that flows through from the federal government to DEVA. So we're hoping to clarify that a little bit while we're going through this. So the wise one care, asking the state for $13 million in delivery system reform dollars, where do these dollars come from and what are they used for? I've heard some say that it's dropping that one care is that true. So when all of your model agreement was signed in 2016, there was this understanding that investments would be required to actually make this reform a reality and shift the way we deliver care. So that's kind of where this funding idea came from. And one care's request for $13.1 million specifically at this point in time includes funds for new projects as well as existing projects and represents funds for both state and federal partners. So some of this money in the $13.1 are funds already being received by one care for projects that are in place. So it would just continue to roll forward, continue to roll those projects forward. So if appropriated by the state, how do these funds be used? So there are specific purposes under the next one of the state's Medicare waiver, which I'm not an expert. So this is under DEVA, but they have outlined that use is for these funds shall be moved into continuing to develop infrastructure to provide better data information to health care providers so they may better serve their patients and invest in community-based population health projects that increase access to primary care consistently across screening, mental health, substance abuse, this decrease of downloads of chronic disease, diabetes, hypertension, and number of deaths related to suicide and drug overdose. So those are the all-care model goals. Another frequently asked question that we get is around salaries and the administrative costs of one care. So the question might be what value do Vermonters get to the cost of administering one care? So we look at this in the budget and sort of four buckets have on the slide here. So the ACO model provides the legal entity necessary to allow providers to work together to care for their patients. The ACO provides, or sorry, payment reform requires investments in transformative change system-wide and by practice. So you need to put administrative money in in order to be able to administer these changes. And transformative change, when I say that, means things like data analytics, information about practice patterns, clinical practice transformation, implementing care coordination, quality improvement. And again, some of this can be centralized system-wide or it's by practice. So the third one, centralized functions are required to succeed under the new models and if you don't have some of these centralized, then they will have to be implemented by practice and be duplicated. Finally, as we've mentioned, Blu-France Sash several times, the federal funding for these programs is made possible through the Royal Family Model Agreement and it's administered through one care. So that's another administrative function. So what do we look at? Or sorry, what is in one care? Is it an administrative budget for FY20? As we discussed last week, 19 is 19.3 million dollars and that represents 1.4% of the proposed budget or total money flowing through one care. And there's more information on this, the administrative expenditure slide from last week including the trends over time. So how does the Green Mountain Care Board monitor one care's administrative costs? There are two budget conditions in our recommendations around this. The first one holds one care to the ratio of some proposed budget. This allows for a range to account for potential revenue changes as it's finalized and it's based on a Green Mountain Care Board sensitivity analysis to make a reasonable range. The second recommendation requires one care to keep administrative expenses at less than healthcare savings in the system over the duration of the agreement. This is a condition that was carried over from FY19 and we are still determining how to monitor this requirement because calculating savings includes savings to the system that are long-term cost avoidance and the value of improved health. So we have spoken with consultants in the federal VACA valueator about how you might be able to calculate this but it is not something that we can calculate year over year and want to look at over the duration of the agreement but it's an important question so it remains in the recommendations. As for the salaries, we wanted to clarify that salary information was collected from one care that's available on our website at the link on the slide on hospital from a hospital salary which is also posted on our website. Another frequently asked question is to do about quality and what do we know about quality? How do we know if one care is improving quality for patients and providers? And the short answer is that we don't know yet. We only have one year of data under the agreement and that's 2018, which was presented to you in November. 2019 data is not available until about a year from now and at that point under the agreement progress is monitored after year two. Quality measures are in one care's contracts with payers and certainly we've talked about this already and there's also the statewide all-payer model 20 quality measures that are separate from the payer quality measures. So when the board looks at this we look at it in terms of what is reported through the contracts and what is reported through all-payer model reporting and we adhere to the reporting requirements that were negotiated therein. So in the budget we collect, again, payer contracts. They link quality with financial incentives and one care also must report provider performance by payer program, the Green Mountain Care Board annually and this is how we will monitor quality through the process. The Green Mountain Care Board also reports to the federal government on the all-payer model of the measures that's done annually. We will also look at quality through the federal evaluation, which CMS has retained the University of Chicago or NRC evaluator we also have talked about last week and we have monitoring to show population health investments link to quality and there's a new recommendation in our conditions today around the dashboard requirements and make this information more plain and available to the public. And we will be working with one care and with input from the healthcare advocate on how to look at that data year over year because the data that you may have seen in public comment or data commentary is not statistically comparable year over year. So we are trying to find a way to look at that year-rear but the contracts specifically say quality is monitored after year two when we have 2018 and 2019 data. The dashboard recommendations new since last year and that new since last week, so we'll go through that. So in addition, so we wanted to therefore follow items you've been asked for and we wanted to go through those and should be pretty quick. So last week we looked at the budget components broken down by the expense areas. I think Maureen you had asked us to look at how to break out the revenue and the funding sources so you can kind of see now that the payer revenue would provide reimbursement and just reimbursement as you would expect, but they're also payer program support and everything is quite small compared to the overall healthcare expenditures which Maureen, some of those refugees were talking about earlier. And that 1.3% from payer program support, 1.2% from state support that includes the 13.1 that has been discussed around ESR funding. Then 1.7% from our hospitals and then other grants that are in smaller amounts. So this is good for your reference. I think it's really important to look at this revenue and those expenses. There was some questioning last week about the potential for one care and making profits and for those profits we're going back to founders, things like that. And I can tell you whether that makes me feel at least a little bit comfortable that we have a hard time really happening is when you look at participation fees from the hospitals, so the hospitals are providing $24.5 million into the system and the board of managers is predominantly the hospitals. And so if there's to be a profit made at the end of the day you can look at it and say that's where the give and take would have gone back. So and I think also there's been a lot of questioning about the size of the growth of how much the revenue has increased at least when you highlight here and you see the billion 362 up top and the billion 362 on the bottom, that's the one point pass through that goes through and that's where the bulk of the increase is. So it's, I think it just makes it laid out this way and kind of see that a little bit more clearly and line out that revenue expense and get into the zero. So for me it's helpful and hopefully for other people who really weren't clear on how that was working through that becomes a little more apparent when they see it laid out. Absolutely, I think we're gonna go through the slide tables and slides that we will try to reproduce year after year so we can have a comparison point. This would be one of them. So I think another question I think we received from two board members is about this 6.04% we didn't receive the support from that but it is unnerving for confidentiality. And then there were also some questions about hospital risk and system level, or sorry, we had upside on system level risk you had asked for a hospital out, correlated to hospital level risk. So we looked at maximum risk liability as compared to D's cash on hand at the hospital level and we also looked at it relative to their NPR and FPP which is straight from hospital budget process. So that is down there for your reference as well. There's also a comment about not just looking at the risk, the downside risk but also the upside risk and opportunity. So we put this on there as a placeholder because this is the data that we have available to us right now but I think what you've heard also is that this is not the only way that we should be measuring opportunity or savings to the system. This is just the contractual mechanism by which hospitals can achieve savings. There are also ways that hospitals can achieve savings by becoming more efficient or through effective care coordination at the ACO level. So I think we just wanna remember that when we talk about this in the future that yes, we should look at their contractual risk and opportunity but it's really much more than that. So I think that's what you've heard from the staff say already is that we need to return to this one of our recommendations that we continue to carry forward about assessing the value of the ACO and really think about how do we measure that full picture. The same recommendation that we presented last week says that the notes on the bottom are about just that so you can follow them from the presentation last week. And this is just a more specific 2021 Network Development Strategy. And I just wanted to say a note on this one in follow up to several board member comments and public comment last week that this is a voluntary provider model. Scale will be achieved under the model of pairs of providers joining the network and that it's the ACO's job to design and implement programs and payment models that benefit providers that are effective at controlling costs, improving quality and reducing administrative burden. So as we've talked about, it's too soon to tell if many of the cost and quality measures are proving successful. However, we can look at providers who are choosing to join the network or not. And so one thing that this recommendation does allows to track new providers, asks the ACO to be more specific about providers dropping out and why and challenges that they're having to network development to help us understand how providers are feeling about the model, what's attractive about it. And so we hope that this will be more helpful to better understand. I'm not gonna read this word for word, but again, this one is also adopted from the 2019 budget order. It's a carryover and this is that one care has to submit written report to the board on the template that we've developed that demonstrates that the payer programs of all highest scale target initiatives under section 6B, 6B of the APM agreement. And if they create new payer programs, they have to submit these to us in a later than 15 days. And again, this may have had some words to think but it's a carryover from last year's budget order. This first one is asking one care to submit one page documents summarizing the benefits of self-funded payer programs, or the benefits that self-funded payer programs receive by participating in one care. And this is just to add to informational materials on our payer programs. Number four is that one care must submit the Medicaid geographic attribution implementation manual to the board once it is finalized with the Department of Vermont Health Access so we can better understand the new Medicaid geographic attribution methodology. Okay, so we'll try to read some of these, but this number five is a reflection of last week and I'm not sure it even changed much except for some very small wording, but it's basically the 3.5% that you just voted on and the 2.9% of ESRD from Medicare benchmark for Medicaid and commercial, the language is similar to last year's since we don't have those rates yet. We'll have to return in this, right, but here are the contingencies in time. So then we have the number six, which is about the maximum on risk that we would allow one care to pay out based on its payer contracts. This is a rollover from the 2018 budget order. Number seven is about asking one care to report on the scale target memo that we posted to our website. We talked a little bit about that last week and so this is just a more precise way of referring to that memo, but it was otherwise the same. Number eight, we have asked, I think this reflects past practice and maybe a little bit more detail, ask one care to come back later in April 15th to present to the board on the following topics. A lot of these showed up in the last week's presentation, but we wanted to consolidate them here so we could know exactly what that presentation would look like and in addition, we added a couple extra things to that list. So you can follow where that was adapted from last week's presentation, but among some of these things, attribution, payer contracts, revised budget, final description of their population health initiatives, hospital dues, hospital risk. So we just kind of want to come back and make sure that we're headed in the right direction and that we don't need to tweak our budget order. And then a lot of that is a requirement to provide all of the documents to support that presentation for two weeks in advance of their presentation so that we can have some time to look at it, analyze it and ask any questions that might be relevant. Number 10 is the same recommendation that we had last week. You know, it's based on a sensitivity analysis that we performed, but kind of anchors one care to their current budget in terms of how much administrative costs we will permit or both things appropriate. And then, you know, based on what the final attribution numbers come in, I think we should take a look at this again just to make sure it makes sense and have a conversation about that. And then one care must implement its first model as it's described in its budget. So we just want to make sure that if there are any significant changes to one care's budget that, you know, they let us go and keep us in the loop so we can consider that relative to all of our other regulatory processes with the board. Finally, before I pass it on to Melissa, number 12, this is about $4 million in reserve. And I believe I was pointing out to you there's a little typo, it shouldn't be 11C, it should be 12C that happened as we were renumbering these recommendations. But this $4 million reserve should be, you know, used only for population health investments and helping hospitals on sustainability plans to kind of enter the all care model and then any temporary cash flow issues that might occur. Otherwise, we would expect that one care would come back before the board to explain any uses of these funds. Okay, so for budget recommendation number 13, as Alina described before, one care will be providing their final budget information for the board in the first quarter of 2020 which includes their population health investments. So this says that if their population health investments are not fully funded as presented in their 2020 budget to us this fall, we've asked them to come back to provide a proposal for the board to consider that describes any funding shortfalls, changes in the programs, programs that would be affected by attribution and to provide an analysis of that on those changes. This mirrors, although a little bit more specifically, Sarah Lindberg's previous presentation around the Medicare dollars. So we're continuing to require one guard to provide at least 8.4 million to the blueprint for health for blueprint-attributed lives for the Medicare for 2020. And this number is based on prior years plus an inflationary rate of 3.5 as described previously. For number 15, we have always had one care report quarterly on their financials and other information quarterly that we're codifying it here. So in addition to the financial statements, we're also asking for information on the population health investments by health service area program and provider type. We're also asking for information on their 2020 complex care coordination programs. It's changing significantly. And we're looking to hear about implementation, enrollment and any potential changes and opportunities. This is adapted from a recommendation that we provided last week. The board is asking one care to use as community specific quality health care investments to address cost and quality differences across health service areas as identified by one care in their variations in care analyses. And the board is asking one to use that those variations in care analyses to support its decisions for quality investments specifically. And then we're asking for a report by April 30th, 2020 that documents this approach. This is a long one, but it did not change from last week. So it's basically asking one care to provide a work plan to evaluate the effectiveness of the population health investments. And it includes who's receiving the funding, what the project is, what the outcomes are and any issues in the implementation of those projects. Okay, this is also a pretty long one, but we presented on it last week. So it's basically asking one care to provide a performance dashboard and a proposed plan for that implementation. So the board will work with one care to determine what that required form of submission is, but it will include population health and financial data by health service area. And we'll speak to how they're meeting their projected fiscal budget and population health targets. So as Marissa spoke to earlier, this has been in our budget order for the past two years. And so over the duration of the all care model agreement, one care's administrative expenses must be less than the healthcare savings, including a estimate of cost avoidance and value of improved health that's projected to be generated through the model. So we plan to, over the course of this year, determine how we'll operationalize this as we are starting to see the 2018 data in full form. There are many qualitative measures that we'd like to also be considered in this when we're considering the system level changes and the value to the healthcare system. So we're currently working with our federal partners who are conducting the federal evaluation and other experts to ensure we are following best practices as we refine this measure. And we will provide progress on this later in 2020. And finally, numbers 21 to 23, we're also in the prior budget orders. One here is still finalizing their 2018 financial audited statements and we've been told they will be delivered one final. And we'll slide with the steps. We present that last week, yeah. We're just, it's exactly what we said last week, but today we hope that you'll vote on these recommendations. And then once that has been decided, we can start using the budget order and then start developing a monitor. Continue developing the monitoring plan. So, we'll leave it there. Any questions you know you have? More comment and question. And just to emphasize what other folks have said here is, I think it's important for people to keep in mind what this is. And if you go to the all-paramiles in the second paragraph, you'll find that it says that CMS, through its Center for Medicare and Medicaid Innovation, to test innovative attainment and service delivery models that are expected to reduce Medicare, Medicaid or children's health insurance program with benefits while maintaining or improving the quality of beneficiaries' care. So, technically, the agreement says this is a test. It may work, it may not work. But we don't have any idea about that because we're just kind of a third of the way down the road. But I will say that in looking at the revenue growth associated with this test, that people, whether it's hospitals or federally qualified health centers or others are voluntarily, there is no coercion here, are voluntarily signing up with one care. And I don't think folks from all walks of life in healthcare in Vermont, including insurers and providers, would be doing that if they didn't see something beneficial to this test. So, sometimes I think this is like, you know, the fight that Ben and Jerry's had with Pillsbury when they said, what's the old boy afraid of? I don't know if any of you probably are afraid of it. To remember that, but that was where Pillsbury was trying to push Ben and Jerry's ice cream off the shelves in supermarkets. And I, you know, I have a feeling here that, you know, there are some folks and I've been around government for a long time that I know are just opposed to government. And there are others that are single payer die hard. But this to me is an effort that the state has undertaken with the federal government. It is a test, participation is voluntary. And I think that we should do that in line as we go forward. I had just a couple of comments. What it, along the lines of Tom, I just wanted to also say, I think it's also important for us to think about the national context because we are not in this alone. And what we heard in the spring at our rural health panel with the national expert who basically works with providers all around the country to figure out how to transform and maintain a sustainable business model given all of the federal changes. We heard in the spring was that the federal government is moving away from fee for service. And providers who are not working on how to transform themselves into a value-based organization are the ones that are seeing the greatest sustainability challenges. There's also, I think, challenges for anyone in trying to transform a large system in that that's certainly hard. And I think that, to your point, earlier in the slides in the FAQs is reflected in the fact that there was recognition that operational transformation requires upfront investment. And if there isn't operational transformation, then, quite frankly, then nothing is going to improve from where we were in a fee for service system. So I just wanted to make that point. In terms of evaluation, I think it's incredibly important to be consistent with the federal government. The federal government, ultimately, will be the arbiter of evaluating this model. CMMI always evaluates their own model and they determine whether they think it worked or didn't work. I think it doesn't do a service to Vermonters or anyone else for us to be inconsistent in evaluation with that federal model because, quite frankly, it just increases confusion. So that is something that I think we need to keep in mind as we move forward in developing dashboards and other items. And I think our staff understands that. I also think it's very important if what we want to do is emphasize prevention and wellness and health over sick care to try and capture foregone costs or avoided costs. One of the challenges, I think, we've had in our state and in our country is that we have not seen the benefits of focusing on prevention because we don't focus that far enough in advance. We will not see the benefit of prevention in one year. You're gonna see it many years out. And so I think to the extent that we keep that in mind, that needs to be factored in. Otherwise, I think we're doing a disservice to prevention, public health, and all of those areas that we think are important for upstream investment in people and people's health. The other thing I wanted to just say is I think I, for a couple of years, have been very frustrated with the way that data flows in the model, as I think everybody is. I mean, everybody wishes we had upfront, totally complete, totally accurate, immediate data, but that's just not the way it works in health care. So I actually really like this process that we developed last year, where we have what I think of as kind of a true up in the spring when we know the actual attribution, we have final pair of contracts that we can analyze. Because I think that if we were to wait and do the budget after we had those things, everything would be to use one of Tom's phrases in the rearview mirror. And so by doing the budget now, and providing these guardrails, if you will, through our conditions, I think that that helps to shape the pair of contracts, but then allows us to come back and evaluate those once they're final. So none of those were questions, but I just wanted to make a couple of points related to things that I think are captured in the recommendations and are important considerations as we look forward. Other comments from board? I'll speak quick, but I just want to thank you, all of you on the team, and also Sarah Lindbergh out there, I didn't properly thank you when you were out there. But I know how many hundreds of hours have been spent pouring over documents, digging into data, trying to get us to where we are today. And I'm really appreciative of that. And the thoughtful set of recommendations I think that took into account your advocates' comments, public comment, each of our concerns. And I've been on a long journey, and many, many hours, but I just want to thank you all. Other comments from the board, Tom? I just have one other object of age or two, very quick. One is, I just want to reiterate that I think that the QHP benchmark plan is a significant source of bringing money that now flows in accordance with the ACO, and that benchmark plan, going back to 2014, maybe, and I say maybe, a little bit out of date, and not fully in accord. I know it's not one carer's domain, it's, Biva's domain and the board's domain, but I think one carer might look over the fence at that opportunity because it's $300 million plus in premium expenditures. And the other area that I'm a bit concerned about, and will be keeping an eye out, has to do with affordability. The ACO is an association basically of payers and providers and insurers, and I worry that if, and this is totally hypothetical, if the ACO really does work well, and there are shared savings for providers and insurers and all the participants in the ACO, but if we kind of continue in the world, in the world of the cost shift and its impact on insurers, and I, at the last meeting, I talked about the last four years of Blue Cross Blue Shield having $2.2 billion in revenue, and only $3.4 million in margin, that if the insurers, if that relationship doesn't get squared away, there may not be shared savings for insurers, and if there are no shared savings for insurers, that will have an impact on what they can do and what we can do during rate review. So I'm always remind myself that Walter Carpenter's comments at these meetings don't forget about premiums, co-pays, and deductibles, and in order for Blue Cross Blue Shield or MPP to have an effect there, they need to have shared savings, and that will be much more highly probable if the cost shift is something that is addressed in our healthcare system. Other comments from the board, Maureen? Yeah, I should make one comment on, there's obviously been a tremendous amount of work that's come through this process, and I wanted to thank the staff, and I also wanna say that there are a lot of conditions in here that need to be met, and we really want to understand whether this is going to work or not. I think we're regulating this, it comes to us, and so we don't know yet whether this is gonna be successful or not, and I think what we're trying to do is look at a lot of measurements, I mean, I think there's been a lot of questions to the board on all the stuff, but the board's just approving all this, and I don't see that as the case, I mean, I see that we do regulate the ACL, we need to have them come forward, and we need to look at what they're doing and see if we approve it, but more so as putting on a lot of traditions in order to be able to measure whether this is successful, also understanding that it's gonna take time to be able to see results or not, right? But we'll be able to look back and say, were we able to bend that cost curve, you know, but it's gonna take a few years for that to occur, and so I think we do have to be patient and see how this works, and I think we're putting up a lot of the things that we'll be monitoring to be able to watch that as we look forward, so I thank the staff for being in there doing behind it. Any other board comments or questions? So I just wanna say that it's a fine line that we walk because we do not wanna create a system that creates additional administrative costs through placing burdens, much like what we hear from doctors on the time of the administrative burden of learning their practice. So we have to be careful that what we ask for is not gonna create a burden that makes it even harder for the practice of medicine in the state of Vermont. I think that the most important work that your team has in front of you in the coming year is the dashboard because the only way that you grow a coalition of willing is a lot of people have to want to believe that it's the right thing to try to improve quality while containing costs and transforming the way medicine is delivered in the state. So I don't think anybody is gonna argue that the status quo was working prior to the all-bearing model because we know it wasn't. So the real question is, how do Vermonters feel comfortable with making changes that as Tom said, may or may not work? In the only way that they're comfortable making those changes is knowing that they're gonna be able to see the results. And so there has to be transparency and there has to be accountability and that's really what the dashboards would provide. And I was really grateful to see that you place the healthcare advocate into that process because we often see some great points of view that we may have overlooked without their feedback. So with that, I just again wanna thank you for your work. And at this point, I'll turn it over to the public for comments or questions. Walter. I guess I'm gonna first hear, I have a couple things. First I wanna thank Tom. He was thinking exactly what I was thinking about affordability and the co-pays and the deductibles. I don't see that changing with ACO, co-pays, deductibles are ways for insurers to ration care to keep profits and their bottom lines up. And I don't see that changing with the shift to value care at all, whether you keep premiums the same, lower, that's not gonna change with the ACO. And that's the vast problem because access is the problem. Tom was talking about affordability and I wanted to pick up on that and I wanted to know how many employees the ACO has that equal 19.3 million dollars in salaries. The thing I'm thinking here is that it's the public and the taxpayers who pay for this and most of them don't get benefits, most of them don't have retirement plans or anything like that. And we're subsidizing the ACO. Another thing is what's gonna happen when they want another 13 million next year after this or whatever figure. I know the board, as the chair said, is walking a very fine line. So those are the comments I have. The second thing is a lot of the public that I talked with is getting kind of icky about it because a lot of these Medicare and Medicaid donors that we pay are going into this private company and they're getting very nervous about that. So that's my comments, Sarah. Okay, another public comment? I think I'm just gonna put them for trouble. I think on the Saturdays, 19.3 million is their total administrative cost. That's not just salaries, just from a... There's salaries in there, but it's not all 19.3. Just didn't want that to get misquoted somewhere. 19.3 million is salaries because they're... Right, and so 11.8 in salaries and benefits, and I believe it's for 77 or so employees, but I have to confirm that. And you did provide a link to YouTube. Yes, the link is on the first or second slide, so. Dale. What does it end up being? I think it's an unknowable, and I keep thinking of this. I think the program had a brand new world after some other books. So this is a serious conflict, and it's a little like our new. Keep wondering which one of you is gonna write the book, The ACO Generation in the Year 2035. But it actually makes sense. When you're looking for what will this do, it's that far down the road. It's the kids of today that are three, four, five years old. It's the things we do for them. It's the things we do for our teenagers. It's the things we do for those that are dealing with substance abuse as parents and those children as they grow up. It's what everybody has to deal with in terms of the younger generation. When those of us that are older are gone, they not only deal with what we tried to do for them, they're gonna deal with what we didn't do for them. So there's an even greater economy of scale in terms of what is my premium going forward? What is my cost of everything going forward? So I keep playing with this in my head. Every comment I've heard makes sense. But I'm just saying it's so true somewhere in there, somebody needs to publish something or something and really get this into the perspective of what we're really doing is looking at the year 2035. Just, I'm throwing out a finger. That's amazing. Because if you said something like that in the 1960s, you're a liberal and very much not in the crowd if you were trying to look that far ahead. Because that was really a now generation. The fact that we are looking that far ahead is innovative in itself. It's a hard sell, but it's innovative and I think it's the right version. Thank you, Dale. It's one of the problems in the world that we live in is when you address social determinants for health, you don't get a one or two year return on investment. It's a much longer timeframe. I can tell you that I'll volunteer to write the book and I'm gonna be on the same timeframe as my buddy, Ham, who told me when I first took the position in 2017, his book was coming out shortly. So noiseless. Any other public comment? I'd just like to respond to Walters a little bit and make a kind of an apples to oranges comparison. So don't take this too far, but when you look at the administrative budget of the ACO, it's at 1.3% of expenses. You can go to the JFO's website and look at Diva, which runs an insurance program. And there is a specific appropriation by the legislature for administration there. And that's at $171 million. And in the last three or four years, it's been 12 to 14% of the total operating budget for Diva, including the program for beneficiaries. It is an apples to oranges comparison because Diva has issues with long-term care, et cetera, et cetera. You can go to the rate review process and see that Blue Cross Blue Shield very proudly says that their administrative expense is 6.2%. So I just kind of throw those out there with some distant benchmarks, but neither of those will ever get to the place where the ACO is, which is now at 1.35%. Any other public comment? I still think that people really don't understand what the ACO really is and what it does. What Grover said was that the whole engine here is the shift from fee-to-service financing to cavitation or some kind of block financing where you can get, like Gax, if we can absolutely guarantee that you can suppress the cost of pressure to rise too rapidly. What I think is very poorly understood is you can't do that. You cannot move from fee-to-service to cavitation without an ACO. There isn't any way to do it. So if somebody doesn't want to do an ACO, and you don't want to have an ACO, you don't want to have one care, then what you can do is you can just get rid of it. You can get rid of the one care. What will happen is you go back to full fee-to-service and what you'll do is you go back to what we had to be had for 50 years, since the middle 1960s, where the inflation rate and health care spending runs four, five, six, seven times the underlying rate of inflation. And when you do that, then when Tom worries about all the cost shift, you'll just take the current cost shift and you'll multiply it by four. So the idea that, you know, this isn't some kind of terrible beast out there, it really just ridiculous. Okay, other public comment or questions? Seeing none, is there a motion? Sorry about that. I move that we approve one care budget with the 23 conditions as outlined by staff, including corrections for any type of rapprochillators. Is there any discussion? If not, all those in favor, signify by saying aye. Aye. Any opposed? Let the record show its unanimous. Is there a second motion that would have to be made as far as making some type of acknowledgement of the certification? No, I don't think any vote is required for certification. We can take our next item. Understanding. That's correct. So the rule says that the appeal is certified until it takes action otherwise. I mean, there's no vote in which case. Thank you very much for all your hard work. Let's just begin. Thank you. So, okay, I started, I'm Kate O'Neill. I'm here with Lindsay Kale, where staff at the Green Mountain Care Board and we are part of the analytics team sometimes refer ourselves as the 18. So we, I'm gonna talk through this kind of higher level overview and then I'm gonna give the meat and potatoes over to Lindsay to talk about the proposed analytic priorities that we wanna share with you today or for your consideration. The Green Mountain Care Board, as you know, is the steward of several data resources, including VCURS, which is for months, All Pair Claims Database, and VUDS, which is for months, Hospital Discharge Data Set. And we use the data in analysis for the Green Mountain Care Board as well as to provide these data to other agencies within the state of Vermont and researchers in Vermont as well as outside of Vermont through data use agreements where folks are interested in questions around lots of different things, but including access to care, health care costs, expenditures, patient utilization, quality. And we also provide broader access to more aggregated information right on our Green Mountain Care Board website. There's a section of the website for data and analytics and right from there, the public, you can access reports that we have prepared where we look to address some of the most common questions about health care in Vermont. The wrong Green Mountain Care Board website, I encourage you to take a look at them. And I wanna just remind you to point out that when we talk about the development of analytic priorities, we're basing that in, first of all, the statute that guides our work around our All Pair Claims Database, which is 18 BSA 9410, and outlined in that statute, there are some duties that we are charged in utilizing that database, including determining the capacity and distribution of resources, identifying health care needs, informing health care policy, evaluating programs around patient outcomes and comparing costs and the like. We also have a data governance council that's a committee of the board. And through the data governance council, the Green Mountain Care Board adopted a data stewardship principles and policies. And within that, one of the policies states that the Green Mountain Care Board data will support timely, consistent, and actionable analyses through setting analytic priorities relevant to recommendations that were provided to us in the Green Mountain Care Board analytic plan. And the analytic plan was compared for us through a contract back in 2012. It's still relevant. And it addresses, I mean, I guess I would say that sort of the thesis of that plan is recommendations that the Green Mountain Care Board construct a foundation of information to support board policy analysis, evaluation, and decision making. And so to that end, the extent of the A team's work is really to support the board in its policy analysis, evaluation, and decision making. So the A team has a whole host of ongoing work, including the stewardship of our data assets, as I talked about earlier when we do that, largely through the data governance council. We also manage a number of analytic contracts, including our contract with on point health data, which is our data aggregation and consolidation vendor for our all pair claims database, B-Cures, Mathematica, which provides, there are analytic contractor for the all pair model, and there are a number of other contracts large and small. We provide data feeds for other state agencies. We are working on the health resource allocation plan, or HRAP, that is a requirement in statute has been a long standing report. And that addresses coordinating interagency data integration providing a health resource inventory and compiling healthcare needs assessment. We also, you heard a lot about the all pair model, federal reporting that we do around quality measures to a cost of care and scale targets, and so Sarah leads the work on that. And we provide reporting support for other reports that the remote care board does, like the expenditure analysis, as well as ad hoc requests, like what do we know about the loss of data because of self-funded employers? ERISA plans not reporting to B-Cures any longer total cost decomposition analysis as well. And so as we sit in our meetings and we talk about our work and where we're going over the next number of years and helping support the Green Mountain Care Board, we have basically two core questions that we come back to. How can the A-Team provide better information to support the board, its staff and the public? And address frustrations around access to data, timeliness of data and the quality of the data that you do have access to. And knowing that there are many, many interesting and important questions to answer, where do we focus? So to that end, we engage in a process to try to begin to address those questions and we developed some preliminary recommended priorities and a timeline for looking at how we might address those priorities and I'm gonna turn over to Lindsay to walk you through that. Thank you, Kate. So like Kate said, based on our core questions, we led some surveys, the staff led surveys with each board member individually and we did that to glean an understanding of each board member's individual analytic priorities. After those interviews, two themes really emerged from all the individual members' input. The first theme was around process improvements for the materials that our team provides and we'll talk a little bit about that towards the end of the presentation but the one that we'll spend the most time on here is point number two, the analytical and reporting priorities that these are common themes that all board members mentioned and so we took time to call those and synthesize them and so this presentation is the first time that we are presenting back to the board our staff's synthesis of everything we heard along with a timeline and the ways that we would deliver that data to you. So out of those conversations came for what we're calling projects. The first three are really research projects, if you will, taking these larger policy ideas and bringing them into more specific questions, hypothesis-based projects and we wanna talk about the purpose of those and what we think they'll inform and some proposed timeline. The first one is a patient origin analysis. The purpose of this project would be to describe where patients come from, their hospital service area and where they go to receive their care, the hospitals and hospital service areas that they travel to. We believe that this project will inform the hospital budget review, the ACO budget review and the health resource allocation plan which Kate mentioned earlier. All of these projects would be, if adopted and agreed upon, they would become recurring reports so you see here that we're proposing the first iteration of that, we do quarter one, 2020 and then any edits would be made and approved upon for quarter one, 2021 and that would be in time to support hospital budget review. So that's project one. Project two is a price variation analysis. The purpose of this project would be to measure any difference in price per service across hospitals. This project would be used to inform the rate review and also the hospital budget review. Because of the scope and the complexity of project two, we are proposing to have it be due in two parts. Part one would be a data validation project where we would combine and compare the V-Cures administrative claims data to the BUDS hospital of discharge data and that would be due by the end of quarter three, 2020. That first part we feel would really speak to the degree to which there is variation and absence of data in the claims. We know that claims, we don't have claims for everyone and we don't have all claims for all of the people in the database, so we wanna be able to quantify that for you, especially when we start getting down to per service line variation. So then part two, the actual analysis of the price variation with that measure of how much we expect that we're off, that would be due at the start of quarter three, 2021. Project, excuse me, project three, also a big one, would be the integration of regulatory decision making in data. This project would really be a proof of concept project. The purpose would be to analyze the impact of the Granada Care Board's three regulatory duties on the healthcare utilization and cost for Vermonters using a specific episode of care example for the proof of concept. And that episode of care is to be determined. We believe that this would inform hospital budget review, ACL budget review, break review and the A-trap. So really all aspects. And again, because of both the scope of this project and also because we've heard a lot of interest in the first two projects, patient origin analysis and price variation, we are proposing that this project be due at the start of quarter three, 2021. Project four stands out a little bit in that it is not a specific research project with set of hypotheses. Rather, this is more of a course, if you will, to enhance the shared understanding of vCures and Bud's data. This course would be offered to all of the board members and other end users for these data to help them understand what data are available in the two data sets. The limitations, so all the caveats that you would expect and some of you wouldn't. And the advantages to each data source because there are lots of advantages and we want to tout that. We think that this would inform, again, hospital budget review, ACL budget review, and subjective need. Really anything that the board has questions about understanding to the best that they can what is in the data sets will help us build questions and build hypotheses that we can answer successfully and accurately. And we're proposing that that is due quarter two, 2020, but offered on a regular basis, semi-annually, maybe, but certainly at least annually, really based on individual's availability to go through the course with us. And on the last slide I have here, just a visual representation of the next two years. It's eight quarters, which when I laid it out like this, I was like, well, that's been a long time. But this is kind of, this is the proposed timeline. Of course, any of this is up for edit and we welcome your suggestions. But this helps space out according to some of the priorities that we heard. Also helps space out and put these projects ahead of certain regulatory obligations that you all have and makes it a little bit manageable. But again, this is all proposed. So we're really interested in your feedback and suggestions. Robin? Yes, thank you. Are you envisioning that data class could be at board meeting or at smaller settings? Yeah, I think it would be up to however you all wanted to receive the information. If you wanted to all get together and think that at board meeting, it would be great. One on one potentially might allow more time for more detailed questions. But I would leave that up to you all. John? On project number two, price variation analysis. The relationship across hospital service areas and hospital pricing is certainly interesting and important. But also how that relates to independent practitioners in, within each hospital service area and across hospital service areas. Just so we all know that some allege that maybe there is a tension there. And I would think that project number two might want to speak to an analytical approach as to whether and why that tension exists. On the board, Marie? Yeah, on project number one on the PCRGEN analysis, we also be able to have to talk about what costs move or what procedures move because it was kind of talking about patient moving from one area to another. What level of detail will it get in there? And also will we be able to show historical trends? I mean, when you start to generate this, you know, you can go back and be looking at some prior quarters or prior years to understand is this changing or the same things what's moving out of certain areas and things like that so we can get some trends on that. You know, as we're looking at it. I would just ask, obviously you have a lot, you've had a lot of repeating requests. So these are the top four that made the list. I'm wondering what did make it to the list? What did you consider when you decide not enough resources at this time to go forward on? I brought that list with me. Quantifying all wasted spend in healthcare and more identifying hospital service areas with high costs and lower outcomes. Explaining the history of healthcare reform to demonstrate where we are now with the all-payer model approach. If not the all-payer model approach, what other options are there in quantifying those options? Reporting on market changes over time to potentially informed changes in spending and pressure on the competing insurance markets. Based on the total cost of care, identifying what procedures are driving costs per hospital service area. For the all-payer model, can you measure how the present day investments impact future healthcare costs? We look great projects too. Yes we are. So how did you, what was the criteria though, which took that long list and came up with this form? The criteria were where there were unanimous interests and although it may not sound like it from the overview that I gave of those first, really the first three projects, those first three projects incorporate really achievable aspects of some of these other questions. I'm gonna choose one here. Reporting on market changes over time to inform changes in spending and how that impacts the insurance market. A little bit of that would have to be included in the project three where we're talking about the integration of all three of the areas that the board regulates just to kind of understand what's our denominator, who are the people in Vermont and really reporting on that and how that's changing over time. Another good example is by hospital service area, areas with high cost and lower outcomes. When we look at patient origin and where patients travel to worry into your question, we will be not just counting patients, we'll be counting their dollars and I plan to capture the total spend both by the insurance side and the membership. So where are our members traveling and choosing to spend their dollars? So that will help speak to higher cost and then we'd have a per member account so we could do a per member account there. So that there are aspects of these other projects that did make it into the plan, the two year plan, but then also I would add that because the questions that we did not incorporate here are much, much larger questions, I think we all on the team felt like these first three projects are really just the start, they're like phase one of answering these much larger questions that we definitely want to help answer. So if after this first year or two year period, we do want to try to answer some of these larger questions, we have all the foundation work in these first three or a lot of it, awesome, it's gonna be great, thank you. The problem is we don't want to give information today. Yeah, the timeline looks really long but I understand the amount of work that's done today. It didn't look like a short timeline. Other questions to report? Not public comment? Dale. It's a two year timeline but could you, could you make like a magazine as you pull this together could you come up with something like a pre-article publication as a e-book or I'm trying to think in terms of going forward as the information is gathered, how do you keep it relevant? Because it's the kind of question that you're always going to be asking but as you pluck that you're gonna have historical data because the data you get now five years from now it's historical or six years which is relevant but then what you do in terms of, so I'm seeing something much bigger here which means how are you going to publish it? We have historical documents in terms of that's where the pre-article comes in so that you could actually be publishing as you're actually working on it in a sense. I think right now the plan is certainly that all of these will be available on our website and that they will be published in real time once they're prepared and shared with the board that they would be available and definitely that they would be recurring reports and they will be updated on a regular basis both with the years of data that become available and the new extracts that we have available to us as analysts and we are working on how to go from what most of these projects are we call them descriptive data and moving to more inferential and potentially one-day predictive data and I think that perhaps that gets more to your question about how do we keep it relevant is being able to use it for more powerful analytics but that's certainly in the plan in the hopes. Yeah, the public comment or questions? Yes. I was just saying for the sake of the hospitals that are going to try to incorporate this into potential data, so what for you? Just to make sure from a time perspective, obviously we're already trying to cram a lot into that budget process and into that preparation and the healthcare advocate questions and the grain mountain care board staff analysis and their questions so I would just ask that we be mindful of that and whether we would truly have the data in a timeframe that would allow it to actually influence our budgets or it would just be something that we would be asked to look at and seek to kind of after those budgets were prepared and submitted but just to give that some thought as to what that might look like. So not really a question just to comment. Thank you. Are there public comments? Seeing none, thank you very much. Is there any old business to come before the board? Could I just say one thing about the normal health services workforce? So we, me and Agatha, are curiously working on trying to get a full, complete draft side deck of which will be our report completed to put out for public comment early next week. So I don't want to give a specific deadline because it may take us longer than we think but my hope is that we'll get about early next week for public comments with comments due in the new year and then in the short timeframe with that deadline. It will be at 7.30 a.m. We'll post that on our website, Robin. Yes. This is our last meeting of the year so if folks in the audience can spread the word that those will be up. We'll probably give up a bunch of the stakeholders that are part of this process. We also have an interested parties email list so we will certainly email that information out to the list of people who have expressed interest in rural health but I think you're going to stay out loud just if people are looking for it on our website. When you're on the homepage of the Green Mountain Care Board on the left-hand side, there's a link to communities of the board. If you click on that, you'll see a link to rural health services staff boards and all of our new materials are posted there. Great. Any other role business to come before the board? Seeing none, is there any new business to come before the board? Seeing none, is there a motion to adjourn? Second.