 So, good morning. This is the house health care committee on Thursday, April 15th, which would be tax day, but some of us would be scrambling around, but I think it's been deferred at least a few more weeks. So good morning. It's nine o'clock on April 15th. And this morning, we have with us invited in a back is who's the director of health care reform for the state and want to have her give us an opportunity to give her an opportunity to update us on the where we are in terms of the reset reboot around the ACO also also about where we are in the process of the all payer model. Moving forward and potential and the negotiations that would be coming up and and frankly to allow time for questions to create create an opportunity for committee members to ask questions. Also, I think it'd be important for us if if you know as the as is able to share more with us about where we are in terms of the federal scene and where we are in terms of what might emerge at least you know what indications there are that have been communicated around changes at the federal level that would help inform us as we think about moving forward with initiatives in Vermont. And later this morning we will hear from the key loaner from one care. Again, I've asked her to do a brief presentation so that there's time for questions. It won't be all the time that we probably would want, but we will. This isn't these these are issues which are ongoing issues and will require multiple opportunities for us to hear as well as ask questions. So with that, I see you are on the screen and there are others with you if there you are. Yeah, still getting used to people popping around the screen. So good morning. Welcome and you've met everyone, but I welcome you to introduce yourself for those who may be listening for the first time on this recording and I'm going to turn it over to you to address some of the broad questions which I just put forward. I think that's what you're prepared to do and then to answer questions. Thank you and good morning, everyone. It's good to see you virtually for the record. My name is Ina Bacchus. I'm the Director of Healthcare Reform at the Agency of Human Services. I did prepare a few slides to help us today in talking about this topic and if I am allowed to share my screen, I'm happy to do that and be the driver. Okay, I think Colleen can arrange that. Thank you. I'm set to share. Thank you. I should say that I've said to Ina that we are different ones of us are different points in our knowledge base around these issues. So some of what I've asked Ina to kind of keep that in mind as some of this as we she does some presentations so some of it may seem too basic or it may seem too complex. So that's that's the range of that's a range of what I think we're we're dealing with here. So but I welcome I'm going to turn it over again to Ina. Thank you. If you think of full screen that would be great then we can it's not quite full screen yet. Excellent. Thank you. Thank you again for having me to discuss the topic of the all payer accountable care organization model implementation in Vermont. I will start by reviewing what type of a healthcare reform project the all payer accountable care organization model is and what kind of a health care reform initiative it is not especially as we are seeing some initiatives that are at the federal level right now such as the subsidies that have been increased through ARPA which are really probably which are really likely to contribute to health care coverage and are really focused as health care coverage initiatives. Whereas the all payer ACO model agreement is focused on payment reform meaning paying providers differently in the interest of curbing health care cost growth and delivering care differently both to improve quality and population health outcomes as well as through changing the delivery of care to be more efficient and to provide for the most appropriate services in the least cost settings. We have a fee for service system as we've talked about before and in this country and in the state of Vermont health care services are largely reimbursed through the fee for service methodology that has been the predominant methodology for health care reimbursement or the the along this the same period of time that we've had a large scale health care coverage programs like Medicare Medicaid as well as commercial coverage. The for service rewards the provision of each and every additional service with re without regard to the quality of those services being delivered or to the ultimate outcomes related to that service delivery. And that's why we through this model through this health reform approach the state of Vermont is endeavoring to pay providers differently in order to drive that transformation in the delivery system which will lead to better outcomes in terms of health and again we are seeking to curb the growth in in health care costs through this model. I think I may have just previewed my own next slide and I apologize how do we how do we address health care spending through this model really the the the root of the payment changes rather than to pay for each and every additional service we're really we can distill the approach of this model to setting a budget for the health care system instead of paying for each and every service regardless of the quality or outcomes and really importantly ensuring that that budget is tied to the quality of care that's delivered and the improved improved health outcomes and that payments are calibrated based on the quality of care and improve health outcomes that there it's not just a budget no matter what no matter if you don't provide the the most appropriate services at the most appropriate time you get paid no matter what it's really looking at whether or not the health care system is is high quality and functioning in a value based model and by value that really means the quality of care that's delivered for for within a within a more reasonable cost growth trajectory. I wanted to point out where we are in implementation of the all payer a co model agreement and this is important because we do and I will discuss an implementation improvement plan. We have through the performance period in this agreement seen very clearly that there are areas of the agreement that we need to improve our performance in in order to maximize our our performance at the end of the day in this model and the model was agreed to with our partners in the center for Medicare and Medicaid innovation in 2016 and after that agreement was signed a performance year zero was initiated to allow for the system to prepare for transitioning to larger scale value based payment arrangements. The Department of Vermont Health Access however offered its fixed perspective payment model in 2017 for participating ACOs and one care of Vermont was a successful bidder on that offering and we'll talk a little later on about the RFP that Medicaid has issued Vermont Department of Vermont Health Access has issued an RFP to solicit bids from ACOs for a next ACO or ACOs based contract. Then then we have performance years one. So when our performance in the agreement starts to be measured is performance year one is 2018 and we are now in performance year for 2021 and there is one additional performance year in our contract with the Center for Medicare and Medicaid innovation. The Center for Medicare and Medicaid innovation was created by the Affordable Care Act. It is a it is provided for as a as an innovation engine for the country to promote different payment models to promote health care reform that can ultimately be broadly applicable across states. However the Innovation Center is testing and has been testing multiple different models. Just just more than 50 models they have tested in the Innovation Center and some of those models like Vermont's are more custom in nature. Vermont is one of three states that has a partnership with the Innovation Center for a truly custom arrangement. Maryland has a partnership as well as Pennsylvania has an agreement with the Center for Medicare and Medicaid innovation. The Center for Medicare and Medicaid innovation was created by the ACA as again an innovation engine in the interest of improving health care quality but also in the interest of developing models that would moderate health care costs growth and could be applied again across the nation as they were developed and tested. And what we see coming out of the Center for Medicare and Medicaid innovation does include the Medicare ACO program and them and and various versions of ACO models for Medicare. And there are many many states with active Medicare and other payer ACO models. In Vermont to change payment most effectively and to align the incentives for providers to change their business model. We and the Center for Medicare and Medicaid innovation agreed that the likelihood of success would be stronger if the major payers of health care were aligned in that payment change meaning Medicare wasn't coming into Vermont as the only payer that was changing payment. Instead Medicare said we'll work with you Vermont on your custom model as long as you also guarantee the participation of Medicaid in paying differently. And you do everything in your power to invite the participation of commercial payers in participating and paying differently. So again can I just step in and say I'm sorry so I see there's a question I wanted to just check in and see whether we could take questions along the way or whether we if there's a natural pause and we'll take questions. What's your I'm happy to take questions along the way. Okay well then I'm going to turn to Representative Burroughs who has raised her hand with the question and I don't want to throw you off track though you know so that's good. Thank you for my question. I am glad you're allowing me to ask the question now because I wouldn't possibly remember it by the end. But it is it pertains to what you're talking about right now and that is does the Center for Medicare and Medicaid Invasion allow its participants to view the specific plans of other states or do you just get the generalized information? Certainly we through the center the Center for Medicare and Medicaid innovation and it has very public information about the models that it's testing. We certainly spent a lot of time talking with them because Maryland had an all payer model prior to Vermont. We did learn from some of Maryland's experience in crafting our all payer model agreement here in Vermont with CMMI. So CMMI shared about their experience with Maryland and we also reached out to Maryland directly as a state that had a relationship with CMMI and really spent quite a bit of time with them to try to learn from their experience and and and craft our model in a way that was responsive to what we were learning from them. So certainly there is an opportunity for learning and the sharing of information about the different models. Most definitely. And and you are allowed to or you have access to specific I think I'm blanking on the right terminology wins and losses the specific shortfalls and and negative outcomes as well as positive ones from from the various states. Yeah, that this the center does make public the results of the of the models and the evaluations that are included with the model and those are all available publicly to us and certainly if we if we have questions about any specific aspect it's been very it's been it's been very productive to have such an excellent team at CMS that's willing to connect us and our team to different parts of CMS or to different model leads on a different model for for instance for our teams to try to better understand how things are operating in Vermont what we might do to modify operations to improve one such example and this isn't related directly to to a model though somewhat is how critical access hospitals that have current reporting requirements for Medicare can participate and those reporting requirements are based on their fee for service reimbursement but when they're participating in the Vermont model they are not in a fee for service model as as is typical and so they need assistance in in how they can satisfy the reporting requirements given that they're in this innovative payment arrangement that's a place where we've been working with CMS and we're hoping that CMS our partners will will issue some formal guidance to them but they've been able to connect us with other parts of of CMS that have work on that area as well as folks who are thinking about payment models for critical access hospitals. So thank you. Thank you. I see representative Pearson has a question before that I want to I want to just touch on something you said and this is pretty basic but I think through I just find it's probably useful because it has to do with language and what that what that leads people to conclude. So you were just talking about the one of the key parts of the model is that Medicare and Medicaid would work to align or that this model allows and expects Vermont to align payments plan payment reform with Medicare and Medicaid and to work to include commercial payers as well as as much as possible. And those are the those are the payers in the all payer model language. Is that what is referring to so as opposed to and I think it's sometimes still in the public eye gets confused with people say well. I'm you know I I'm for the single payer model not the all payer model and and conflating different language pieces is that is that so the all payer refers to the fact that this is payment reform aligning Medicare Medicaid and hopefully commercial to the degree possible. Meaning those major payers as we remember that very helpful pie chart which we've just recently revisited in committee again if you look at Medicaid Medicare and the commercial insurance market that's that's that's that's the world of payment for health insurance in this current era that we're in so I'm asking a question but making a statement maybe you can help comment on that. Your your statement is accurate. The the terminology all payer really really refers to the 3 major payer types that are covering vermonters that are that cover vermonters for for health care services and aligning those 3 major major payer types in paying differently for health care services so that providers aren't aren't as much and and this is a place where improvement does need to be made. We need more we need to see providers move more of their revenue to risk based models and to and to revenue models where they have a fixed payment that they can rely on that is predictable and stable and that they can operate from in that in that idea that the health care system should have a budget within which to work and to best operationalize and provide for the care and needs of of vermonters and so the idea being that if if the health care system only has a budget for Medicaid that then the health care system is still working under the fee for service incentive for the other reimbursement that that it's receiving and the incentive is not as strong to transform the the delivery model and to do and to deliver care differently within the budget versus delivering care in a system that rewards for each and every additional procedure or act activity and and having those payer types aligned in providing that different and more flexible payment is also important so that providers are being paid for their time in in doing activities that the fee for service system does not reward and so the fee for for service system is transactional and you go in for a particular service and and your health care provider is reimbursed for delivering that service. But if the health care provider needs to pick up the phone and talk with other providers about the best way to deliver that service or to coordinate about the next step in your care plan with other health care providers, those activities are ones that are not reimbursed by fee for service. Those those coordination activities are a key example of something that's not enough of a widget to be able to fall into the fee for service reimbursement category and we want to provide health care the health care system with the dollars that they need to enable the time that's required in those sorts of activities that really do have a really important impact on health and outcomes for patients. Thank you and and I don't want to kind of over beat this issue and then I want to turn to represent Peterson who's a question but so that what you've been describing is the alignment of the major payers Medicare Medicaid and commercial insurance and that's the all payer terminology single payer. I think it's helpful. Your first slide which showed the one two three four of health care financing health care coverage payment reform and delivery system reform. Yes. The quote single payer terminology really falls within number one which is a health care financing model not a payment reform model. Is that fair to say? I think I think single single payer means different things to different different people. It certainly could fall into the health care financing model. It could also fall into the health care coverage realm as well. That yes. Okay. Maybe I'm making things more confused and helpful. But I just I just find myself the terminology the language is I think sometimes not helpful in these two distinctions that that have been used in the public eye for many years now and I think adds to some confusion at times. So I agree with I agree with you that when we use the the payer terminology it seems like one is a substitute for the other but they are very different things. That's I guess that's the point I was trying to reach represent Peterson. I kept you waiting but you've at least one question at this point I imagine. No that's that's fine cherry. I really appreciate your question because I just learned something about what all payer really meant. I you know I'm as a new person in this I'm still struggling to understand some of this and that's going to lead to the question I have and I've heard it since I've we've started this these discussions fee for service versus fee for health I guess I would call it and overall a health quotient that you want to get to. I just have such a hard time understanding how you would pay health care provider for my health versus paying him or her in my case when I go in for a check up or go in for a consultation and then get referred to a test or get referred to someone else or have a yearly exam of the various types that I have. I struggle with what you mean when you say payment for for health versus a payment for fee a fee schedule fee for service. I'm looking at the words here. I really struggle with that and it sounds like it's what we're trying to get to and maybe are at but I just I wonder how it affects insurance and health providers. Do they get different amounts of money? Do they do they make less under the system? Do they make more? Do they like it or I wonder how it affects the system and I've never understood how you pay somebody for my health. Maybe you could help me. I there are a couple of very good questions embedded in in your in your overall question and I'll first talk about how you end and and also say that we have some really good resources in the Department of Vermont Health Access that could go into real depth and detail with you about how the budget is developed because I think it's a very good question. Well where do you how do you know how much health care providers need in order to operate business be open and have their their doors open to provide care for individuals. How do you understand what what is required for that and there's been a lot of work in developing what we refer to you as as value based payments which can have components. The value based payment can have a fixed component to so that that budget within it. But that value based payment is it is looking back at what health care looks like historically patterns of utilization for patients historically. So it does take into consideration these are generally what the patients in our panel require in terms of health care services and based on bundling up all of those requirements then a reasonable then a reasonable budget can be set. I think there's that that is the most grossly overgeneralized description of that that I think is imaginable and there is a lot of devil in the details to that it the the generation of the of the budget or of the benchmark for what the health care providers are ultimately held to is it is it is a pretty scientific process and there is and there is also some risk in that imagining a situation like the global health pandemic that we're experiencing that certainly the rows off our expectations for what health health care services look like. So there are there are it's by no means a that's a good answer you know thank you for that and I assume that will that changes with with your sex with your age with your you if you bundle those things that are required to keep you know I'm 69 to keep a 69 year old man healthy that as time goes on. Well my case of those numbers will go down. I hope now can probably go up as you as you age and things change. So is is that does that come into it. You're your demographics obviously must absolutely that's factored in a good example is in the Medicaid program when we think about how the we call it rate development the team calls it rate development and those rates tend to look quite quite different for children than for adults and you can imagine that's because children and are are in most cases much healthier than adults do not have in most cases is not in all cases of course but children as a as a general group don't have the the prevalence of chronic disease for instance that we see with the adult population. So that's absolutely right that beneath that those things are all taken into consideration. They're factored in. Okay I have many more questions but we won't have a mouth. Thank you. Can I just say that I think these are the kinds of questions that really are important to ask because even for folks who are been around for a while it's like some of these there's there's there's many issues that there are to really understand and I would just say represent Peterson. I think you may have just coined a phrase that I found useful when you said well as opposed to fee for service fee for health that it kind of captures something in a way that makes the the to when we say value we're talking about value based payments which I think is what you're I think that would be and we will look to you now that's what that's the phrase that's used in the jargon of this world right now to contrast it to fee for service but you know in some ways fee for service versus fee for health kind of captures somewhat more clearly in my mind and so you may have just coined a phrase so I think I think it captured the idea represent so I'm going to go turn to represent page and we will have more giving a more chances present and also ask more questions. So represent page. Yes. You know our our health care in Vermont is very difficult in it to understand for for anybody including members of this legislature for this this body and it kind of reminds me of Winston Churchill's comment where he said it was a riddle wrapped in an enigma talking about the former Soviet Union and I kind of look at our health care system in that way sometimes but I'm looking at your slide here and I see payment reform curb health care costs growth delivery system reform improve quality and population health and I have to ask mean our health care costs continue to go up. I'm not certain that our quality of health care is has really improved that much can you could you explain that or tell me why I'm wrong in such an assessment and then I'd like to go back to the previous slide where you talk where you have the where we'll just talk about this slide right now. I don't think that your assessment is incorrect and that is why we are why we are in this program of health care reform health care costs growth it is is not has not been on a sustainable trajectory health care quality should always be a focus of continuous improvement but in particular health care health care quality in recent years there are some there are some key areas where where we need to see improvement. As far as the all-payer model as a reform initiative going back to the timeline slide now we are in performance year 4 we have had two complete performance years one and two with their being over that time as anticipated a growing scale of participation in the model and I'll talk more about this as an impetus for our improvement plan. We have not reached the scale of participation in this model that's necessary to really tip the balance in terms of a revenue change for providers and for the system. So do we know when we're going to change that you know are we just going to you know give have another 5 years and and and basically where we are now at what point you think we're going to see you know some change some proof improvements. Yes. One one of the one of the things that the Center for Medicare and Medicaid innovation has observed about the models that it's tested and is testing is that when those when those models have voluntary components it's hard to set it's hard to set a deadline for or it's hard to set a mark draw a clear mark for a conversion to a different revenue model. I think there's the question was asked earlier about where CMS is headed. I think there's reason to believe that that CMS might be headed for some more mandatory payment change where payment changes. It's not a voluntary change to a new revenue model Medicare will only pay for instance in a new way Medicare is only willing to reimburse providers that will accept that change revenue model and that gets to your question about when will the balance be tipped. I think that there's that there's a balance to strike for providers in terms of their readiness to participate in these in these new models and at the same time I think that as the federal government continues to drive harder on on changing the way that health care is paid for that we may see the balance start to tip more in that direction. I don't think it's it's reasonable that we would see this overnight change going back to how many years we have in the fee for service system. The the ways that the that the system is structured around the fee for service reimbursement and the readiness of of health care providers to assume financial risk right that giving having to manage a budget means you're you're at risk if you don't manage well within your budget. And the ability of providers to manage financial risk and the readiness of providers to to manage financial risk certainly does vary by different provider types and provider size we need to be focused on how more providers become ready to assume risk and can take risk and and that that's an important piece to drive more more revenue towards towards that towards the new model of budget but there there's also a glide path that can be created where providers incrementally assume more risk where providers have have are at risk for some portion of their performance but not fully at risk in the direction that we would like we would like to see I think it's it's reasonable to consider that it's reasonable you know to consider looking at at timelines for for risk assumption. And if I may chair I have one more question regarding this slide. Chair. Everything I read about the governor and Secretary Smith it looks like we're going to continue on after 2022 with a with an agreement I believe one care is that correct. First of all and one of one of the things I wanted to say and meant to say earlier is we we have an agreement between the state of Vermont and the federal government that allows the state of Vermont to to customize how Medicare works in the state. Our agreement is an ACO model agreement but our agreement is not a contract with one care for mine. We through this agreement offer offered that ACOs in Vermont can be paid differently and there's no prohibition on other ACOs operating in the state of Vermont. We only have one care. There is one highly unlikely we're going to get another for others. There is one ACO operating in the state of Vermont today and that is also the ACO also has to be an attest to join the state of Vermont in this model to work with the state of Vermont towards the model goals and that ACO is one care of Vermont. We are the the agreement that we have with Medicare does allow for the state to have a custom Medicare program which I think again we're one of just three states that has that that considerable flexibility with the Medicare program. Medicare isn't is an essential participant in healthcare reform. As the chair mentioned it's it's about a third of the healthcare coverage in the state if we're trying to do something that's consistent across the payer types and that is consistent for Vermonters across the lifespan. There's no way that we can do that without Medicare's participation but Medicare is a very large program and can be a very blunt instrument for a small state like Vermont. Medicare may make mandatory certain aspects of of its portfolio of paying differently and that may not work well for Vermont right now with an agreement with Medicare. We have the opportunity to shape how Medicare programs could work in the state of Vermont that might be that might much better serve us a very small state with a unique you know with a unique rural makeup and I think that having a Medicare agreement isn't a very important part of our healthcare reform portfolio. What that looks like though for the future we need to engage in a public process to solicit feedback we need to look very carefully at what is working in this current agreement and what is not working one of the things that we know is not working the way that we would like it to is in fact how Medicare is paying ACOs in Vermont. We'd like Medicare to pay ACOs in Vermont more like how Medicaid has developed the payment model. That's something that CMS our partners have signaled that they're willing they're certainly they they can consider whether or not we can change that but I wouldn't say that we are are signing the dotted line on the next agreement without going through the negotiation process to determine what we can walk away with as a state and even more importantly without completing that public process that we are going to be launching in the spring summertime. Possibly consistent with the the ending of the legislative session. Thank you very much I'm so there's there's some kind of feet of I guess it's not there now. So again I think we're was represented golden were you in the queue first or represent black. Yeah that's fine I'm I'm just wondering if you could talk about providers being able to assume more risk because that's kind of a conceptual term and I'm not sure people understand what that would mean in a real world example. I can I yes I can I can give it my best shot and then it is it is technical and different for different providers certainly and it might be a question you would also ask one care for month as it is developing risk models and has risk models and where providers are at risk. But essentially what I mean by that is that a provider has to have a healthy enough balance sheet and the ability to manage in a scenario where if the spending goes over budget and the provider is accountable for that spending over budget that that can be absorbed so to speak in the in the providers overall financial picture. Some providers also may not have the ability yet to to be able to work with an alternative payment that's different than fee for service there's there is a mix of provider readiness and provider ability to manage within a risk structure and that's another that's another reason for potentially providers to be working together in a risk bearing construct because of the different degrees of financial of financial backing within that within that construct. Right right now and I think this is something to explore further with one care for month so they can talk to you about their delegated risk model and how they work with providers. But another important point to make is that with the Medicaid program the Medicare program and the commercial program the risk contract is between the payer and the ACO so there is one risk contract Medicaid contracts with the ACO and the ACO is at risk and and then if the performance of the overall network of the ACO is is better or worse than expected either the ACO is able to generate savings and distribute those savings across its network or the ACO needs to need is is accountable to pay back for that risk and I have another slide which I can explain that with the Medicaid program but it is important to know that at the high level these alternative payment contracts between Medicare Medicaid and commercial payers are payer ACO contracts. So if I may follow up so thanks if I understand this right. The the risk is to never mind go ahead. Welcome back. Yeah I'm just going to understand because what I what I recall was that you didn't have scale you didn't reach scale on the provider involvement although I understand that most of your involvement is through the UVM practices and I was just wondering how this risk possibility and exposure is affecting practices in participation. It the risk the risk exposure does affect participation and I'll give an example of that. One of the and it was a recommendation for improving in the in the performance in the agreement in particular in light of COVID-19 and its impact on the financial health of of Vermonters of Vermont providers and Vermonters when when you're at risk as an entity at risk you need to have money in reserve to manage that risk in the case that in the case that you don't perform that you don't have a good performance. We for Medicare the risk the risk corridors previously were 5% risk corridors and that risk corridor meant that the ACO ultimately was was liable for more risk but then it was contracting with providers to share in that risk and it and again the ACO one care Vermont I think will be better suited to describe to you exactly how their risk model works. But we know that the risk that was delegated for hospital participation was making it difficult for for hospitals for hospitals to participate based on on their financial situations. We modified the Medicare risk corridor so that the risk was not as significant for 2021 and we worked with our partners at CMS to do that we did that in light of the experience in the pandemic and we saw a provider come into the model that had not been able to participate in the Medicare program previously and a provider came into the model with that new risk structure in place that provider may have been able to come in and this is a hospital Rutland hospital Rutland Regional Medical Center Rutland Regional Medical Center may have been able to come in you know more slowly over over time but I think particularly in 2021 this performance year performance year for after what I would say is a near complete disruption in 2020 with a certainly a destabilizing impact on healthcare finances that risk corridor modification made it possible for for Rutland Regional Medical Center to join this model in the in the 2021 performance year. Even even as things have been very much disrupted in terms of the financial picture. Representative Black and Representative Donahue. I realize we realize we haven't gone through this presentation but I think I think these questions are important for us to be able to put forward so we'll we'll kind of keep juggling back and forth if that's okay. Well I have lots of questions but I'll save them till the end my my question is that is Medicare paying us for this the state are we getting money for Medicare to roll out this model this initiative. Medicare does not pay does not pay the state to roll out this initiative. There was one year of startup funding in year 0 and that start-up funding was not for the state rather it was it was to it was to sustain the funding that Medicare had been providing for the blueprint for health and for the SAASH program previously through a different Medicare demonstration which was called the multi multi advanced practice medical home demonstration. I think I think I kind of that's not quite I don't have that name quite right but is the MAPCP demonstration and so performance year 0 Medicare did provide the state of Vermont with the funds to keep funding for blueprint and SAASH in that year and those funds did come directly to Vermont as the as the administrator of the blueprint program and then we're distributed to SAASH those funds now come to the state of Vermont they come through the state of Vermont as modified total cost of care they come into the state of Vermont but they only come in through the ACO they don't come to the state as an entity. So we're no longer we're no longer getting money for blueprint and SAASH but the money for getting it to to the ACO to replace it. The money for blueprint and SAASH never came to the state of Vermont previously in the demonstration it went directly to providers from Medicare. We had one year where it didn't go directly to providers because the providers weren't that the one care Vermont was not set up in a relationship with Medicare in order to receive that money and distribute it to the blueprint for health and SAASH but very importantly the demonstration that I spoke of that was providing Medicare participation was was canceled. It was a discontinued demonstration. There was no other path for the Medicare dollars to be available for blueprint and SAASH at the end of 2016 that demonstration was sunset put to bed and was not maintained and and in part that was not a demonstration that was sustained because there were not enough or significant savings demonstrated through it with the exception of of Vermont which was demonstrating savings. However, Vermont as as one small state wasn't demo wasn't able to offset all the savings that weren't being demonstrated in where the demonstration was happening in other states. Okay, I guess I'm just trying to really get at what do we stand to lose if we discontinue this after 2022. We if we diskin that it our relationship with Medicare is very important in terms of having an aligned the ability to align reform initiatives across the payer types to make them as uniform as possible because and and the administrative burden is is a key aspect here that also drove this initiative and certainly knowing that there are different sets of rules and requirements and payment mechanisms and and programs across the three major payer types was was a piece of information that through this model. We were trying to address so we lose we lose that opportunity for Medicare to participate in in Vermont based reform. That's that's one piece we also lose that Medicare participation in blueprint view the dollars that flow from Medicare for blueprint and and sash is another piece that would be lost. Those are things that Okay, and that's what funds of the community health teams right. Yep, the Medicare portion. Those teams are also funded by Medicaid and commercial payers. So that's that is a that is a multi payer program as well. Okay, thank you. Thank you. I'm going to so we've been it has been helping us nonstop for close to an hour and I'm going to have representative Donahue ask a question then I'm going to suggest we take a five minute stretch off screen break for everybody to be able to just get a break and then we'll come back and continue and likely take another break before we switch to hearing from one care but represent Donahue. Thank you. Although my first question was if we're going to drill down or if you're going to drill down a little bit more on Medicaid financial risks and issues in a later slide, I'll hold off but if not, I can ask now. I don't I don't want to jump ahead of your slides if if it's going to be a later discussion. I was going to as as you know, we haven't seen the performance in the model that the performance in the model needs to be improved. We've recognized areas for improvement with one care of Vermont improvement with the state of Vermont and how we approach the model. There are areas where we want to work with our federal partners to improve as well and ensure that the Green Mountain care boards of regulatory activities are supporting the model. When we met when we made recommendations about how to improve some of those recommendations were really informed by the scale of participation in the Medicaid program and that's what I was going to talk a bit more about is the performance in the Medicaid program and what we've seen in that program that does have a more advanced alternative payment model mean meaning it's it does have a truly fixed component of the payment model. We really we looked at at Medicaid as as a program offering to understand what so we're seeing more participation in Medicaid. So what's working about Medicaid and then how could we take what's working in Medicaid and recommend that we that we pursue those approaches through the other participating payers and so Medicaid you can see the scale of participation is greater in the Medicaid program as well. I was I was going to highlight how how a few key outcomes of the Medicare excuse me the Medicaid contract with with one can I have to just move you down on my screen so I can be able to read how that's working. So I did I did want to highlight a few things about the Diva Department of Vermont Health Access which is operates Medicaid program is working with one care in 2019 Diva in one care agreed on the price of health care upfront and actual spending was more than expected. So for Diva and one care that actual expense spending being more than expected one care was taking that risk for the spending because one care shares financial risk with Medicaid one care has to pay for a portion of the spending over the agreed upon price. And for the 2019 performance year one care Vermont paid approximately 6.7 million to Diva. If Diva and one care hadn't had this risk sharing arrangement then Diva the Vermont Medicaid program would have paid the entirety of the spending in excess of the expected price. And we I was only going to add that this is a very it's a very common liability in a fee for service system where you do estimate what you think your fee for service spending is going to be if the fee for service spending exceeds that however and the you know the the department pays pays that they've paid every every fee for service with no sharing of that risk. It might so my question I think steps back a little bit further back from that when the all pair model was first you know conceptual and developed. I think one component of it was that Medicaid part of its commitment was to be increasing rates a little bit closer to meeting costs rather than underpaying and therefore increasing the cost shift. And you know from a legislative point of view it's great when the Diva budget isn't you know skyrocketing because rates are going up but but in fact we haven't increased them and I think the effect of that is that when there are savings they increasingly go only to Medicaid not to commercial payers and therefore we're seeing a real increase in the cost shift which seems to be connected with the all pair model and us not increasing our payment our kind of fair share of the payment for what we're purchasing is that because of course the Green Mountain Care Board can can look at the whole financial picture but they can't regulate Medicaid rates we're the only ones who can do that so if the cost shift is increasing because we're not even keeping pace let alone reducing that gap which I think was one of the sort of agreements on the large scale then we're increasing the cost shift and that would mean commercial insurers who are the smallest participants in terms of that end of the scale would have even less incentive to join because they're not going to get to share in the savings as much if if the bulk of the savings end up going to Medicaid. The Green Mountain Care Board is required. We are required as a state to look at how the all pair model impacts cost shifts and I don't want to I don't want to inaccurately represent what we've looked at and would invite Green Mountain Care Board to talk more with you about that analysis. But I do think that the upshot is that the ACO program is not exacerbating the cost shift the cost shift does exist. Absolutely but the program itself is not is not making that worse. Okay that may be something we should hear from the Green Mountain Care Board because I had heard that it might be making it worse but that it certainly is not improving it which had been one of the you know one component of what we were supposed to be doing as part of our agreement with the federal government. All right. Thanks. Thank you. Okay I am going to just I'm going to take executive charge here and suggest that we take a five minute screen break. I think give everybody a chance to stretch. We we have several hours ahead of us still and I think that will serve us all well. So I right now. Well let's say let's say we'll be back at 1015. They'll give us a little look. Yeah a little more than five minutes. Let's be back on this.