 I see four board members and I'm here. So I'll call to order the Green Mountain Care Boards hearing of March 2nd, 2023. Thank you all for being here today. We have just two real substantive agenda items, the minutes from last week, and then an update and deliberation relating to one care Vermont's fiscal year 23 budget resubmission with a focus on primary care payments. Which will be presented by Marissa Melamed, our Health Policy Associate Director here at the board and Russ McCracken and our staff attorney. First I'll turn it to Ms. Barrett for Executive Director's Report. Thank you, Mr. Chair. I want to announce a clarification on our press release for our meeting next week. It was incorrectly listed for one of our presentations that we'll be hearing next week from Springfield Hospital. We actually had it listed as the FY22 actuals that they'd be presenting to us, but to clarify it is Springfield Hospital Update on FY23 Q1 financial performance. And we have adjusted the press release. So I wanted to clarify for next week's meeting the correct title. I also want to remind folks about an ongoing, well, actually two public comments that are open. One is ongoing regarding the all payer model and the next potential model. If folks have any comments on that, please send your comments our way. We would share those with our colleagues at Agency of Human Services and the governor's office as they are leading the implementation and the work on the all payer model. I also want to remind everyone that we're accepting public comment on the information that was presented last week on the FY2017 UVMMC enforcement action. We have a potential vote scheduled for next Wednesday, March 8th. So please share your comments to the board so they can consider them in time for that vote. And with that, I will turn it back to you, Mr. Chair. Thank you very much. We'll turn to the meeting minutes from February 22nd, 2023. Is there a motion to approve the minutes? So moved. So moved, seconded. The board discussion. All those in favor of approving the minutes from February 22nd, please say aye. Aye. Aye. Aye. And the minutes are unanimously approved from February 22nd, 2023. And just for the record, I have a hard stop at five o'clock today. I don't think we'll go that long, but we'll try and make sure we're observing that because I actually have to go. So with that, I'll turn to Ms. Melamed and Mr. McCracken. Thank you, Chair Foster. Good afternoon. Just please hold a minute while I set my windows up to present. Okay, are you able to see the slides? Not yet. Not yet, okay. Hang on just a minute. It looks like it's going through on my end. So I might do it a different way. My apologies. You appear now, Marissa. Great. Can you just hold for one minute? Sorry, I'm having a technical problem. Just give me a minute. Sorry about this. I'm having a problem. It's not working the way I expected. Kristin, would you mind presenting them on your end? Thank you so much. Okay, can everybody see that now? Sorry about that. Great. All right, so again, my name is Marissa Melamed, Associate Director for Health Systems Policy. I'm joined by Russ McCracken, staff attorney. And we're going to talk to you today about the January 30th budget resubmission from One Care Vermont, specifically about the impact of the Blue Cross Blue Shield Vermont withdrawal on primary care payments. Next slide, please. All right, maybe the internet's just a little slow today. Looks like it's working. So here's the context of the background. Blue Cross Blue Shield announced on December 20th that it did not plan to continue participation with One Care in fiscal year 23. This was just one day on 12-21 before the board vote on the One Care budget. We were notified by One Care on 12-21 of this change. The notification at the time left an open door for negotiations to resume. So this was left as a bit of an unknown when the board deliberated on this budget in December. So the Green Mountain Care Board's 12-21 vote included a requirement that One Care resubmit their budget by January 30th, 2023. That guidance specifically required that One Care reflect the budget assumptions at this time on the effects of the withdrawal of Blue Cross Blue Shield from One Care program. So we knew when they resubmitted, this would be something of an interim resubmission that it was a sort of best guest of those particular components of Blue Cross Blue Shield but that it would not be a final budget for FY23. That final budget is due on March 31st along with any budget amendment request from One Care to adjust the originally approved budget. So this interim budget is the budget we have before us today, this is the information we have to date to discuss not the final budget. I'm gonna go to the next slide please. So we have received some public comments on this issue. The public comments just to summarize they expressed concerns about the impact that the Blue Cross Blue Shield withdrawal from One Care will have on Vermont's payment reform efforts and on primary care providers. This includes loss of fixed monthly payments for Blue Cross Blue Shield lives to independent primary care practices through One Care's comprehensive payment reform or CPR program, reduced alignment in payer programs such as quality measures and goals, reduced population health management and preventive care initiatives and loss of value-based incentive payments. Also I would want to acknowledge there's been some press coverage and legislative testimony taken on this issue as well. Next slide please. So overall to summarize the withdrawal the impacts of the withdrawal Blue Cross Blue Shield from the One Care program. There is a reduction in lives that are tied to an ACO cost and quality accountability framework. There's also a reduction in risk and opportunity for shared saving. There's a reduction in population health management per member per month or PHM PMPM payments that are committed to the primary care providers in the One Care Network. And there's a reduction in fixed payments to independent primary care providers through the comprehensive payment reform GPR program and a loss of the fixed perspective payment pilot. We'll talk a little bit more about each of these in the following slide. So you can go to the next slide. So reduction in lives tied to an ACO cost and quality accountability framework. Here's just an overview. It's more than 30% reduction from the original budget. So it is significant. It's approximately 88,000 attributed lives budget for Blue Cross Blue Shield. I'm using approximate and rounded numbers in this presentation because the budgeted, the budgeted amounts are tied to an estimate. So we rounded off the budgeted amounts just for illustrative purposes. This is not an exact number that you will find in One Care's budget submission. So that's approximation. As well, it is $471.3 million in total cost of care including fixed perspective payment and FPP in an ACO arrangement. So the bar charge there is just showing you over time. The green, sorry, tiny is the fixed perspective payment. Blue is fee for service. So you can see the kind of the impact of that from the original lease submitted budget which is the second to last bar. Next slide. Regional budget One Care anticipated an increase in the risk sharing arrangement for Blue Cross Blue Shield. So that will not materialize without Blue Cross being in contract with One Care. So there's less opportunity for shared savings or in shared risk in this revised budget. Next slide. Okay, so these next two have the biggest impact on primary care and I read these. I'm not gonna read it again. So we can just go to the next slide and I'll walk you through what that looks like for primary care providers. So this is a problem that's caused by One Care and Blue Cross Blue Shield's failure to reach an agreement for 2023. Primary care providers suffer the most immediate impact of this failure of One Care and Blue Cross to negotiate a contract because the contract was meant to provide for direct investment in primary care providers in addition to fee for service payments. So they're 30% or greater than 30% fewer lives and fewer healthcare dollars in a value-based arrangement where payment is tied to quality outcomes and total cost of care target. Not only does the money come out of a value-based risk arrangement where providers share in the savings and losses but investments are being made through this model in primary care providers. The system is relying on to coordinate and manage care before people end up in the ED and hospital inpatient for avoidable issues. So to make that clear, it's not just that the payments revert from a value-based arrangement to fee for service but there are actually additional investments being made in these providers through this agreement and that's a loss that you don't get back when you remove these lives from the program. Investments to strengthen primary care including providing resources to expand capacity and existing practices and to recruit additional providers is a key consideration for ACO budget review. And the intent of today's meeting is to discuss how the withdrawal of Blue Cross Blue Shield affects the ACO's budget as it is designed to support primary care and what, if any, remedies are available to the Green Mountain Care Board and the ACO as we consider the revised budget. So I'll describe how the arrangement is supposed to work on the next slide if you can go to. So the withdrawal of Blue Cross Blue Shield causes a reduction in the PHMPM payments that are committed to primary care providers and the one care network. So here's how. PHMPMPM payments are based on attribution, the function of attribution. For each attributed life, the payer commits to a PMPM payment and one care commits to a PMPM payment. Note all of this goes to providers, none of this is for administrative costs. Attribution is based on an agreement between one care and the payer. So to understand who those lives are that you're tying these payments to, you have to have an agreement with a payer and their member. Well, for their members. So the PMPM is a match, that word's a little confusing. It's not a match, it's in their equal, but basically the payer says we'll put in a certain amount and then one care says they'll put in a certain amount. So it's a match of 325 from the payer and then $1.50 from one care, which is a base payment and a dollar from one care, which is a potential bonus. There's another aspect here, which is that primary care providers also pay into an accountability pool, which covers their portion of any risk. They paid equivalent of 150 PMPM, which they can earn back. So this essentially is 325 as their monthly PMPM base, but they have the opportunity to earn more if they meet the reporting and quality requirements. So absent the payer contract, the money budgeted by one care for the PMPMs is not tied to any attributed lives and therefore those lives are not included in the cost and quality accountability framework of one care and one care doesn't get any data on those lives. Can go to the next slide. This slide illustrates the same point just with example data. The payer side of the revenue, which is in blue, the one care revenue, which is in green gets you to the total amount that could potentially go to population health management PMPM payments, which is orange. Again, it's a function of attributed lives. And note that the table is illustrative data based on a rounded average attribution. These are not exact numbers. So you could take that rounded attribution times it by 12 to get member months. You see that with the payer revenue portion is at 325, gives you the potential payer revenue. For the one care side, there's a min and a max based on the base or their potential bonus that they can earn gets you to the total. But if you take those lives out, you don't have anything to tie it to. So in the revised budget, one cares budgeted 1.8 million in PHNPMPM payment expenses for the Blue Cross Blue Shield contracted lives. So this is the budget amount that they expected they would be paying for their portion of the match. And again, the revenue source for that investment is from hospital participation fees. You can go to the next slide. So there's another aspect here, which is there are some primary care providers, independent primary care providers specifically can opt to be in the comprehensive payment reform, CPR program. They're also impacted by the loss of the Blue Cross Blue Shield contract that this works a little bit differently. Go to the next slide. So probably should have reversed these slides, but that's okay, I'll go in this order. So the effect overall on FPP and CPR, the Blue Cross Blue Shield withdrawal removes the FPP pilot. So that gets us down to 0% commercial FPP. The overall fee for service FPP ratio, which is something the board tracks will increase because we're losing lives and the bulk of FPP is in Medicaid. So the overall ratio increases, but that's only because we've lost a good chunk of commercial lives. And there is a change in policy for the CPR program to include MVP attributed lives to kind of offset the inclusion of the Blue Cross Blue Shield lives. And we can get to that. The next slide talks about a little bit more. So here's how the comprehensive payment reform program works and the impact. This program is designed to move participating independent primary care practices away from a fee for service payment model to a value-based payment model with a fixed per member per month payment. Their PMPM capitated payment is a blend of dollars from Medicare, Medicaid, and previously Blue Cross Blue Shield, plus some investment from one care, same as the other primary care program. The PMPM for providers in this program replaces fee for service for these payer programs. It includes a capitated PMPM payment, PMPM payments for both core and non-core services. And so with the Blue Cross Blue Shield program no longer contributing to the CPR program, providers will not receive payments for their Blue Cross Blue Shield patients within that capitated payment. So it will revert to fee for service. And then there is a small amount of hospital dues that are also committed to, they're sort of attached to these lives that would come out of that capitated payment or any amount that providers are able to earn through that program. So overall, their capitated payments will decrease, but the Blue Cross Blue Shield lives will revert to fee for service. And again, as we mentioned, one care was exploring. And I think maybe at this point has adopted adding MVP attributed lives to the program. And we could hear more from them on that and how that works and how it offsets the loss of the Blue Cross lives. You can go to the next slide. So one more thing to note here about sort of potential remedies that are on the table. One care also let us know that there are some agreements or potential agreements with self-funded plans. So one care indicated in their January 30th submission that they had signed a memorandum of understanding with the University of Vermont Medical Center to have a direct contract. Those self-funded plans that would be retroactive to January 23. So through that contract, they regain attributed lives and restore healthcare dollars and accountable care arrangements for 10 to 14,000 self-funded patients. So that was sort of put them back in. And again, we would want to hear more from one care about how that works and how that offsets the impacts. Go to the next slide. Okay, so that gets us to the bottom line. So what is the bottom line? So there's 1.8 million in budgeted hospital dues that are no longer tied to attributed lives. There's almost $98,000 and a modest decrease in operating expenses that are also associated with the Blue Cross Blue Shield lives. So that gets us to a $1.9 million bottom line to be evaluated in the final budget. So a lot of words below here. These are copied and pasted directly from one care's budget resubmission context because it's their statement about this bottom line number. So I know it's a lot, but I think it's worth reading so that we understand what one care has said so far. So there's submitted documents that the budget resubmission reflect changes to attribution, the total cost of care, risk reward, payer support revenue, population health management expenses and operating expenses that are linked to attribution. In total and all else equal these changes result in a net reduction of funds that would ordinarily be asked of hospitals through participation fees. However, because the participation fee amount needs to be thoroughly and holistically evaluated by one care governance, no change has been incorporated at this time. This approach results in a bottom line profit of roughly 1.9 million in the submitted materials. Though for clarity, the fact that the submitted template show a profit in no way reflects a plan to generate a profit, nor does it reflect a decision to reduce participation fees by the full amount. Any change to the participation fee amount in the resulting bottom line or changes in CPR and or additional contracts will be incorporated into the revised budget due later this spring when we also have final numbers for all programs. So essentially they're saying, we're leaving this 1.9 on the bottom line because we need to reevaluate the whole budget to decide how to either reinvest or reduce these fees that were expected to be collected from hospitals for this program. So I wanted to let their statement just speak for itself. You can go to the next slide, 16. We have some information on the Blue Cross Blue Shield side of this equation as well. On January 20th, Blue Cross sent a letter to providers confirming that the 325 PMPM payment would continue through June 30th. And then on Monday, February 27th, Blue Cross Blue Shield committed to continuing these payments for all of 23. And there's a link to that press release there. Payments will be made based on current attribution, meaning based on January 2023 active enrollment for each quarter, they will, providers will receive quarterly payments paid by Blue Cross directly to the practice. Previously, these payments were made from Blue Cross to one care quarterly, who then distributed the 325 to the practices, I believe one care distributed to them monthly. The purpose of the payments are called primary care support funding. It remains unchanged. There's no restriction or requirements for the practices to receive the payment. So the sort of reporting aspect is lost for the moment. And the payments are made for qualified health plan beneficiaries fully insured large group, self-insured health plans, including for employers who chose not to participate in the risk program. This is the same as it was when they were in the program. Blue Cross made these payments on behalf of these beneficiaries. Some are wearing a risk arrangement and some were not. Only the programs in the risk arrangement also got the match from one care because those lines were participating in the one care program. You can go to the next slide. So just a little bit about the process to date. So after one care is January 30th, interim submission, Chair Foster requested additional information from one care on February 9th to address the immediate impact faced by primary care providers. There are a couple of questions in there about kind of what any immediate decisions that one care had made. One care responded to this letter on February 17th. Both of these letters are linked on our website. The February 17th response letter deferred decisions about the primary care payments to March 31st, to the March 31st resubmission. To another important note, so one care leadership and governance is reevaluating the ACO budget and will submit a revised budget based on final contracts and attribution and any budget amendment request by March 31st. So one care's sort of response to this would be expected by then, if not sooner. So what we're doing today is bringing the issue before the full board for deliberation. Go to the next slide, which is how I'll frame up the discussion today. So the opportunity today is for the board members to discuss their preferred approach. So what we're talking about here is most specifically the 1.8 million in budgeted hospital participation fees that were directly tied to the Blue Cross Blue Shield lives. The discussion could also include the $98,000 approximately that's in operational savings in the interim budget. It does not include the Green Mountain Care Board ordered 2% admin reduction from their original budget, which we would look for in the final submission. So potential approaches are listed below, but first I'll note that all funds must be reasonably related to ACO activities to be compliant with federal law. So basically what that means is ACO activities are things that promote accountability for cost and quality for attributed lives and better managing and caring for attributed lives. For example, promoting patient engagement, patient health management or evidence-based medicine. They can't just be payments that are made to primary care providers. They need to be made in a way that furthers the ACO's goals of reducing cost or improving quality for their population. So here are the potential approaches that we have identified. One care could reduce the budgeted hospital participation fees based on the loss of attributed lives. So this would accurately reflect the loss of attribution, but it doesn't provide any relief to impacted primary care providers. Two, they could reinvest those fees into existing one care primary care programs. Here are some possible examples. They could raise the base PNPMs in other payer programs. Here's some pros and cons. That would provide timely relief for impacted primary care providers in 23. It could lead to a reduction in the base in PNPMs in 24. So what I mean by that is we don't know what the blue cross-bushield arrangement might look like. So if one care made this decision for 23 to up those PNPMs, we don't know if that would continue or be able to continue in 24. They could also choose to raise the bonus payments amount in other payer programs. Again, this would provide relief for impacted primary care practices and avoid that potential, making it kind of look like there's a reduction to the base the following year. But the downside is that the bonus payments are paid later after quality measures are final. So it's not as timely. I would also say another way to put it is that if you raise the PNPMs in some way in other primary care programs with the other payers, it may appear like it's sort of one-time funding that goes away. Another option is to reinvest the fees into other ACO programs. Kind of the downside here may not go to primary care. It could, you know, it would overall increase investment in population health or keep it the same as was budgeted. And again, it could appear to be one-time funding. Also leaving it open that there could be other options that we have not considered, but these are the ones that we identified. And with that, I'm going to turn it over to Russ briefly to give you a little bit of information sort of on the procedure here because we haven't kind of encountered this sort of interim budget review before. So I'm going to let Russ say a few words about that. Thanks, Marissa. Russ McCracken, staff attorney with the board. Marissa did a great job of setting up the general process here. So I'll be pretty brief. As Marissa mentioned, one care is submitting a final budget to the board by the end of this month. And that budget will be reviewed and deliberated on by the board. This meeting today is really set up to review what is a significant issue and to give the board some context, the opportunity to discuss the issue together and discuss potential approaches and what board members would like to see in one care's final budget that's submitted on March 31st. There's no vote scheduled for today. So the board isn't voting on anything today. But if a board member wants to propose that the board take some action, a vote can be scheduled and noticed for a future date. And procedurally, there are a couple of ways we can handle that in terms of making a motion during this meeting or during a future meeting. So with that, I think I will turn it back to you, Marissa. I think that is all I have today. I'll turn it over to you, Chair Foster, for discussion and questions. Great, thank you both very much. I had one quick question, I have a couple of comments and thoughts I wanted to throw out for my fellow board members. But one question I had is, I believe the data is that somewhere in the neighborhood of 60 to 70% of providers in Vermont work at our hospitals. Do we at the board or would OneCare have information indicating what percentage of these primary care providers are at hospitals? I don't have that readily available, but that is something that we should be able to get from the provider list or have OneCare give to us. Is it reasonable to assume or presume that a good amount of this $1.9 million, if it were reallocated to primary care payments, would go back to the hospitals? Is that fair? Yes, it's fair to say that a good chunk would go back to hospital primary care practices. Okay, so I appreciate you guys putting this together. I know it's been a lot of nights and weekends and I believe one or both of you are on vacation. So thanks for stepping up to do this. You guys did a great job and you've treated this very urgently and seriously. And I think it reflects the importance of this issue to the board. I would say at the outset that I would be supportive of the board requiring OneCare to fund primary care payments at the same level as before the Blue Cross Blue Shield withdrawal. I think we all recognize that primary care providers are incredibly important to ensuring the health of our monitors and also to our healthcare reform goals. In my mind, they're foundational. And yet we've learned since I've been here that their practices face significant financial challenges and they have extreme administrative burden that's difficult to maintain and there are too many retiring or leaving the practice and that's not good for our state. I'd also note that numerous actors in Vermont have encouraged primary care providers to participate in the ACO model and the primary care providers have and they've taken on costs and burdens to do so. OneCare has encouraged primary care providers to be part of this and the primary care providers have stepped up and they reasonably expected to have this level of funding available to them this year. And it was critically important. They budgeted for it, they planned on it, they changed their practices, they've taken on burden to be able to do this because they thought this money would be available. And to no fault of their own, that financial support that they're expecting in January went up in smoke in mid-December and I find that extremely unfair and also detrimental to Vermont and our healthcare system. I expected perhaps incorrectly that OneCare's revised budget would put forth adequate solutions to ensure the primary care providers have the same level of financial support for the Blue Cross withdrawal. To me, this really is a four or five alarm kind of situation that needed every possible solution analyzed and practical solution proposed so that these primary care providers knew where they would be and not kind of just left in the lurch. I'll note also that Blue Cross has found a way to do so. And within a month of their announcement, they announced they'd provide support for the primary care providers for the first six months and then I guess it was just last week. They indicated they found a way to be able to make those financial payments for the rest of the year. And I appreciate Blue Cross recognizing how important these funds are to primary care providers and for the decisions they made to do so. I did wanna just state for the record how appreciative I am of you, Marissa and Russ and the entire ACO team. We got that budget submission, the resubmission in January. You guys really went full throttle to try and come up with ideas and assess ideas and to work through them. You updated me, you provided me analysis and brainstorm, you assessed all the possible steps that we could take to address this. One of you was on calls with me up till 10 p.m. at night and you took it very seriously and I'm grateful that you did. We approved One Care's budget in December, around $15 million and a big part of why I voted in support of it, frankly, with some reservations was because of the population health and CPR payments to primary care providers. In my view, it was one of the things that One Care does very well and it's something that I think I would actually like to see One Care support at increased levels in the future. So absent this $1.8 or $9 million from the population health programs, in my view Vermonters are getting less for their $15 million investment this year in the ACO. So I just say that that's very, very important to me and I think it should be there. I think that One Care should include that funding and should find a way to ensure that primary care providers are my mind mate whole. While I support requiring One Care to direct that money to primary care providers, my view, and I'm curious to hear the other board members' views, I'm in favor at this time of having One Care advise what's the most economical, productive and efficient means to do so. It's One Care's role and job to come up with ACO programs and in my mind it's in the best position to make recommendations as to what mechanisms to fund the primary care providers make the most sense. So I guess I could change my mind on that but at this point I think it probably makes sense for One Care to say how they're going to do that. One last kind of issue is I have a concern, I think you sort of flagged this, Marissa, is that Blue Cross is doing this for 2023 and we don't know what's gonna happen in 2024. And so that could be a lot of money that's not available should One Care not be able to retain Blue Cross for next year. So I don't know if One Care is here today or not but I'm flagging that issue for One Care. One Care needs to be working on that and planning for that contingency today. If you can't keep the largest private insurer in the program then the ACO's value and the costs look very differently. And obviously I've never run an insurance company but I'd guess that the best way to attract them is to have programs that they view as working well and saving their members money. And to me this really means fair, objective, rigorous evaluation. That's something the board, particularly member homes and the healthcare advocate have been pushing One Care to do for a lengthy period of time and it's now part of the board approval. So I'd also think that it's just critical and vital to attracting an insurer to participate going forward. Lastly, I'd say that the, I think it was $303,000 was reduced from the admin budget by the board in December and then there's 97,000 in savings that have so far been identified. I would also support adding that into payments to primary care providers if there's an appropriate mechanism to do so. I have no other questions or comments but I thank you guys for taking us up and doing this so properly. With that, I'll turn it over to my fellow board members. I'll turn to Ms. Lunge if she has any questions or comments. Thank you. And thank you, Marissa and Ross and the rest of the ACO team for a very complete and thorough analysis and presentation. I really appreciate it. So in thinking through this issue, I'll start with potential solutions. I also am supportive of One Care funding, the primary care practices with this additional dollars and having them advise the best way to do so. I think I'll say one of my concerns is that if this is one-time money that it be used in a one-time fashion because I think otherwise we'll be back in the same position next year with primary care practices feeling a cut. I'll say I am very disappointed that the parties were not able to find a solution. I don't consider Blue Cross's commitment of 3.25 as being the same while that will provide some relief for practices on a financial basis. It is a significant decrease in potentials chaired savings that would be available for the practices from the transformation. So it's a big deal to me that it's not in a value-based payment and that it's pretty much prolonging fee-for-service payments. So to me, that's not the same. I would also say it takes two to tango. So I would really hope that Blue Cross would also come back to the table and consider ways to ensure that they can participate in one care's value-based payments. Certainly they both need to work together to figure out the right way to do that. I obviously don't have information about the exact breakdown but from my mind not knowing the exact breakdown I put responsibility on both parties. I guess that's all I'll say for now. Thanks. Member Merman. Yeah, thanks and thanks again to Marissa and the team for the presentation and all the hard work that it went into it very informative and helpful to understand this issue. I share my colleagues' concerns about the inability to come to an agreement between Blue Cross Blue Shield and One Care but also support the idea that this funds that One Care has can be reinvested into primary care with One Care working out the best solution for that. So I echoed both the prior comments from Chair Foster and Member Lunge. I appreciate them. I don't really have anything other to add other than just the continued support I think in importance of healthcare reform and delivery with the importance of primary care as the main mechanism that we've been relying on we need to support the primary care providers if they're the mechanism to try to improve care for our population. Thanks. I'll turn to you, Ms. Member Holmes. Thank you. I guess I feel like we're gonna be it's gonna be an echo chamber in here thanking our wonderful team for keeping us abreast of all of these updates, disappointments that the parties could not come together. I share Robin's concern that while it seems like the 325 is keeping them whole, it's not tied to any kinds of value-based payments. And so there's a concern that I share with Member Lunge about that. I do feel the same way as others do that primary care investment is critical to containing costs to improving population health. So I support all efforts to infuse more resources in primary prevention and care management, which is what these dollars were meant to do, but again, tied to quality and improvements in population health. I like the idea of it being tied to one-time funding. It is, this is, you know, I'm concerned about what happens next year if it's just added on top of the per member per month amount, because if it's not then their next year, it looks like a cut. I do think that at this point in time, I mean, they are reaching out to their board. One care is reaching out to their board. They're trying to consider what to do with these, this 1.8, 1.9 million dollars. I think we can signal to the ACO that we would like to see these earmark dollars continue to be allocated to primary care, let them identify the ways, the best ROI on how those dollars could be spent to improve population health, and really give the primary care providers the resources that they need to make the changes that we hope to see in the delivery system. So I don't wanna be overly prescriptive at this point a month before they're gonna resubmit anyway. But I think all of us so far who have spoken are signaling this is really important. Primary care investment is really important. So I think I'm just gonna leave it at that on this point. I just wanna raise something that may seem tangential, but actually it may not be. And that is that I think we need to have a really strong understanding of the primary care landscape. And one of the things that I think would be helpful, and this is maybe to Susan, to you, to I know that AHS did a study last fall about primary care access in the state. And as a supplement to the wait times investigation or inquiry from last January. So I guess I'm, you know, part of me as we're talking about primary care and the importance of primary care, it'll be really helpful. I guess this is a sideline, but it's related to this is to understand what were the results of that study? You know, where is access compromised in the state? I don't know whether that could help inform where some of these dollars are going or where we can be improving and ensuring that our primary care providers have the resources they need to stay financially viable and to stay in the state. So I guess I would say it's a tangential topic, but I know it was something that AHS decided in the fall and it might be helpful for us to understand where the pain points are in primary care access and in the context of this investment in primary care through one care. So those are my comments at the moment. I look forward to hearing others. And member Walsh. Thank you. I'm joined my colleagues in thanking Marissa and Russ and team for their analysis and really echoing things that have been said so far late last fall, we tentatively approved a budget with $1.8 million for population health and CPR payments. There was a distribution mechanism that was dependent upon another entity and that distribution mechanism fell apart. But one care has touted its ability to pass through dollars and distribute money. So my hope is that they're able to find another way to distribute that money that we approved in their budget. The money's there. It's figuring out how to distribute it now that the arrangement they had fell apart. Those things happen, but the money's there. I hope they find a way to get it to primary care providers. And as close to a fashion as their budget had it. But like my colleagues, I think I'm not trying, I'm not running one care. I think they're in the best position to figure out the best mechanism for that distribution as a pass through organization. I think member Holmes had a good point about trying to target any funding. That'd be a great feature that data analytic program within an accountable care organization could do. A strong data analytic program would help distribute the money in the most useful means. The fact that that has not been going on for the past five or six years is continues to be telling to me. And that's it. Back to you, Chair Foster. Thank you. I guess I would, I had two things from member Lunge's comments that jumped out at me. And one is, I guess, Marissa or one care if they're here. If there's a mechanism to address the decrease in shared savings so that that amount of money is also remains available, I would be certainly open-minded to any proposals to counteract that issue. And then, because I think Robin's right. That's an important change in what we had before and what we have now. And then the second thing is my understanding is the Blue Cross payments for this first six months are not tied to value-based performance. They're just providing the money, which I guess I kind of understand because of the exigencies of the situation, such as you will, is Marissa, do you know if that's the same for the second six months of 23? I believe so. I believe it's the same for the full year. Okay, I had no other questions or comments. And I'll turn it over to the healthcare advocate for any questions or comments they may have. Thank you, Chair Foster, Sam Pysh off to the healthcare advocate. I'm gonna keep my video off today because my whole family is unfortunately battling a stomach bug. So I can't really characterize myself as being camera ready. But I wanna thank Marissa and the ACO team for your presentation and also the willingness of the board to deliberate this topic at this time. The HCA believes support for primary care support is critically important. So with this in mind, we think option two, bullet two, presents the most sound and preferable approach because first and foremost, it provides at least a bridge for this year to continue the support for PCPs, while also being responsive to previously stated concerns from one care about their ability to make this happen. And I think it's also important that this recommendation aligns with regulatory oversight requirements and objectives of the board. So thank you to Marissa and team for doing that. And we look forward, I mean, also there are a lot of kind of uncertain pieces with this budget and we look forward to one care's budget submission at the end of the month and continuing to participate in the process. Thank you. Thank you, Mr. Pysh. I hope everyone in your house gets well. I'm also not camera ready. I'll have to thank my uncle Andy for lending me his suit jacket and shirt for today's hearing. And with that, I'll turn it over to public comment. If you use your raise the hand function, I'll call on you in the order in which the hands are raised. Sarah Berry, please go ahead. Good afternoon, Chair Foster. This is Sarah Berry. I'm the Chief Operating Officer for One Care Vermont. And I wanted to start just by thanking you for the opportunity to have this conversation today and particularly for the work of the staff. I think this is an incredibly complex issue and topic. And they did a really nice job of laying it out in a way that people could understand and really consider the multiple facets of the situation. So just as many people have said, we at One Care as a provider led network believe in the value of primary care, believe that it is foundational and want to continue to make our best efforts to support that system, to really pay attention to how they're supporting preventive care, acute care, and really thinking about them as the cornerstone within their local communities for providing that continuity. So as has been mentioned, One Care has been taking significant action over the last few weeks since Blue Cross' decision to withdraw from a contract. And that includes immediately working with our primary care network and engaging with them about what their needs are, what might be possible from a legal framework. And we prioritized at the top to rethink our CPR program. And as several people mentioned, we have now successfully taken board action and been able to bring the MVP lives into the CPR program. And those funds are flowing out on a monthly basis to our providers, along with the standard Medicare and Medicaid payments. So I think that's a very rapid success and one that we've certainly heard positive feedback around. The next thing that we've really focused on is engaging with the UVM Health Network around a new plan to be able to recapture some of the lives lost as Marissa spoke to. And we will certainly have more to share with you in our budget submission there, but we are making very good progress in that arena and that will bring those lives back into a value-based care arrangement with appropriate risk and reward possibilities for primary care as well as for the continuum of care. I can't speak in detail today to the conversations about the funds for primary care that are in discussion. I can say that it's a very active conversation that will happen through our governance process in this March cycle. And we will certainly give you full information when we submit that documentation and the strategy and approach that goes alongside it. So having said that, I just again really thank the staff and the board for having this open conversation. I think this is a critical issue for Vermonters and certainly for our healthcare providers and OneCare continues to see itself as part of the solution. Thank you. Thank you for your public comment. Next, Ms. Sharon Gutlin, please go ahead. Thanks. I definitely support primary care fully because of the value of prevention, but physical therapy is a profession that provides preventative services as well. We support reduced healthcare costs in the prevention of injuries and surgeries and pharmaceuticals when applied. And when incorporated in chronic care management can help prevent all of the diseases that are included in chronic disease, diabetes, hypertension, depression even. And PT with direct access, it's had direct access for a long time. So people come often first to us. So we are evolving into being more primary care, not equal but complementary to collaborate with primary care. And I think that that's the best dollars spent in any profession, whether it be the traditional primary care doctor's office or physical therapy practice. If we apply prevention that pays more, it pays not only for the direct care of the moment, but in the future. And my PT practice is included in OneCare technically, but it really, it doesn't share in any cost benefits or cost sharing is a risk. I would like to see it somehow evolve to that. I understand how challenging that is, but one way that I feel like I can get a shoe in if there's some extra dollars and it wouldn't take much is to support this innovation in applying medically directed exercise to the chronic care management model. So we've been doing that since 2003, but it's to a small group because insurance doesn't cover it. So it's 100% out of pocket. But we have experienced people in this program reverse their chronic disease going from dozens of medications seriously down and seeing their mental health improve radically. We know that the number one injury that gets a personal verse 65 into the ER is a fall. And primary care doctor's office is really aren't doing that of checking the balance and the physical therapists have been doing that for years. We also keep track of pretty much, we're like primary care of the muscular skeletal system, which is really fundamental to health. And I see the primary care doctors in the doctor's office take more of the functioning of systems, but the muscular skeletal is a system. And I think that if we tap into the potential of what a physical therapist can provide, I see annual visits of both because we can catch when there is a decline because we check range of motion and strength and endurance and all of the factors that might indicate a disease. And we have and doctors offices have certainly got referrals from us because of our concern. We also see people coming off the streets for free consultation and have had a lot of opportunities and prevention. So I'm just putting a plug in that we don't have blinders on to what preventative care entails and make sure that we have funding to the wide breadth of possibility, especially in innovation. And I wanna be a partner in that process of identifying and supporting preventative care within the profession that I know really well from not only being a PT, but being a PT practice owner. So if you can squeeze carve out a little bit of funding, come talk to me, I'll put it to good use. And my program really does depend and empower the individual in taking ownership of health, which is really rare in chronic disease. And that's why we struggle. So my whole vested interest from the get go is helping that person figure out what it is that they need to take on their care indefinitely for a lifetime. That's it. Thanks. Ms. Cutlin, thank you very much for that important comment. I think your points resonated with a lot of us. So thank you for sharing them. Ms. Julie Wasserman. Okay, yes. Julie Wasserman, I do freelance work with health policy. My comments concern primarily one cares Medicaid enrollees. And it does relate to the discussion today about primary care because a lot of the care that Medicaid enrollees receive is primary care. Medicaid's continuous coverage requirement that has been enforced because of the pandemic is ending in less than 30 days. Diva will be resuming its normal eligibility and enrollment operations at that time. And so within 30 days, Diva is back to its routine eligibility and enrollment operations. The result of that will start to see that in on May 31st, Medicaid enrollees who are no longer eligible will lose their coverage beginning May 31st. The Urban Institute produced a report several months ago in December and that report estimated that 29,000 Vermonters are expected to lose their Medicaid coverage because they're no longer eligible. 29,000 lives, Medicaid lives is a lot. It's an estimate. So we'll have to see how that pans out. But many of those lives are covered by one cares Medicaid ACL. So I suspect that this will have a noticeable effect on the number of Medicaid lives that the ACO serves this year. So my question is, can one care take this into account in its revised 2023 budget, which is due on March 31st? Great, thank you very much for raising your question. Next, Robert Hoffman, Mr. Hoffman, how are you? Please go ahead. Hi, thank you, Chair Foster. I wanted to make a comment about the impact of potentially lost shared savings. It's important to point out that on this matter, savings for Blue Cross Blue Shield historically have been at best immaterial and historically mostly non-existent. So it actually gets at the heart of why you all are having this conversation today. If the ACO had been able to demonstrate value on behalf of its attributed lives, there likely would have been shared savings, more material ones, and at least Blue Cross would have something they could point to to demonstrate that the model was working. I think an important number, I'm not sure why everyone's overlooking it, it's in the presentation today. The nearly $100,000 modest savings from administrative burden associated with one third of the revenue being lost equates to just one basis point. That's not a percentage point. That's a basis point of the total $15 million administrative budget. It's actually closer to half of one basis point. So we can reasonably infer that the ACO is telling you historically they allocated half a basis point for working on and performing work on behalf of Blue Cross Blue Shield. If that's all they're saying they're losing or gaining in terms of efficiency in their budget. So I think it's important to reflect on that as you all consider the budget submission at the end of this month. Does that seem reasonable to you that for a reduction in one third of revenue, we're only going to reduce the administrative budget by half of one basis point. To member Lunge's comments, I think she does a disservice to the public today to suggest that this is nearly a breakdown in negotiations. Blue Cross, unlike Vermont's Medicaid program sees itself as having a sacred role as a fiduciary to taxpayer and premium payer dollars. And the issue is not a matter of breakdown in negotiations, but it's an issue of non-performance. And echoing member Walsh's comments during the budget season at a certain point, this starts to feel wasteful when people can't access care, when morbidity rates are increasing as are mortality rates. In some cases as a result of not being able to access specialists in a timely manner. So it's disingenuous at best for members Lunge's and Holmes to suggest that they take exception to the negotiations breaking down. And moreover, they disavow their own role historically in ignoring as early as 2018 public comment indicating grave concerns about non-performance at which time member Holmes went on a rather lengthy seven minute diatribe condescending to the public about their misplaced concerns. We are at this point in the conversation because we have a too big to fail organization that hasn't delivered the results for a major commercial payer. And that is a non-performance issue. And I trust that you all will dispense seeing this as just an annoyance of poor contract negotiations, not culminating in what you'd hoped for and see this as a major signal, much more than a canary in a coal mine that this model as has been publicly litigated, legally litigated for five years now has very serious systemic flaws. And if you all wait till the end of 24 to figure out what your plan B is, you will have set up a too big to fail organization without some off ramp that reasonably supports the primary care practices most of all because you have not visioned a way to disperse quality based payments to the state of Vermont as you all remain existentially committed to that form of reimbursement. Thank you. Okay. I don't see any other hands raised at this time. I appreciate all of the feedback and thoughts. I'll just say, as board members, we all certainly try to make our best judgments and we often fail to make everyone pleased, but we appreciate everyone raising their hand and sharing their views. I think it's really important to the process. I'm quite often criticized myself probably correctly sometimes. And so we appreciate people raising their hands and sharing their views. And in a lot of these insights are things I had not thought of. So I appreciate the feedback on these are very important. And with that, I think we are done on this portion of today's hearing. I have nothing else. Ms. Malamud and Mr. McCracken, are you guys all set? I have no further comments today. Thank you. Great. Is there any old business to come before the board? Any new business? And is there a motion to adjourn? So moved. Second. I'll second it. All those in favor? Aye. Aye. Aye. Thank you everyone for your work and Marissa and Russ in particular. I appreciate it. Have a good day.