 Good afternoon and welcome back to the Green Mountain Care Board meeting that was recessed this morning till 1. And the first item for this afternoon's business is HIE and I'm going to turn it over to Sarah Kensler to tee up that conversation. Sarah. Sure. Thank you. Let me just share my screen so I'm able to see the slide. We are. Excellent. Thank you. I'm Sarah Kensler, GMCB Director of Strategy and Operations and I'm here to give a staff recommendation on the 2020 update to the health information exchange strategic plan and the 2021 connectivity criteria. Quick timeline and process reminder, Siva submitted the plan to the board at the start of November. We held a special public comment period on this topic through the month of November and received one written comment. On November 18th, Siva and Vital presented the HIE plan and connectivity criteria and I walked through the staff assessment about submission and then on December 1st, Siva resubmitted the HIE plan with some minor edits. Today we'll hear a bit from Siva about that resubmission and you'll receive a final staff recommendation. Regarding resubmission, following the board's discussion on November 18th and again on November 25th, Siva resubmitted the HIE plan with some minor changes in four areas. And actually we have Emily Richards, HIE program director at Siva on the line today and she is going to speak to those changes herself. Sarah, can you hear me okay? We can. Welcome Emily. Thank you. Sarah, if you go to the next slide, I've got the details there. Thanks. So the first year is a reference to the new federal rule on price transparency. Thanks for the input from board member Cullum on that. In late October, CMS and two other U.S. agencies released final rules on price transparency that require health system actors to open up information about the costs of specific medical services. So if you remember the Office of the National Coordinator and CMS have also recently released rules that call for opening access to patient health records and claims data. So working in conjunction, IT developers might look at this and say, okay, we're going to make applications that open up all of this new data to patients. So that's a new piece of information that we added to the policy section in the plan for something to sort of look out for and plan for in the next year or two ahead. We added a note on timing of new data integration efforts. The project timelines in the plan are expected to shift to better align with existing efforts whether it's the all-payer model implementation and evaluation, the progress made on our social determinants of health pilot, or work with the designated agencies as impacted by the COVID response work. So the timing there is for illustration purposes and to ensure that folks are reading know that we're considering all facets of the HIE ecosystem that will impact how new data is integrated into the system. But we've added a note there on the timing itself. The third one here, clarification on next steps for social determinants of health. You may remember that we talked about social determinants of health pilot between the Agency of Human Services and One Care Vermont supported by grant work. So the next step for that is for a population health subcommittee to take that pilot and consider how data would be integrated into the onto the VHIE and exchange social determinants of health data specifically. And I added additional language here to clarify that that work will involve ensuring that confidentiality and protections of that data are at a minimum the same as how we treat health data today. There's a lot of work ahead for that subcommittee to do, but it seemed important as board member Pellum pointed out to point out the fact that sort of the floor of our work will be ensuring confidentiality of the data as we do today. And finally updates the protocols for access to protective health on the VHIE. Board member lunch had some great edits to add greater clarity to this description of when a public health authority can access data and the definition of the public health authority itself. So those have been included in that in the revision. Thank you so much Emily. Does the board have any questions for Emily before we move toward the staff recommendation? I don't have a question I just wanted to say thank you to Emily for her help in making those changes. Thank you. Ditto for me too. Thank you Emily. I appreciate all the input. Thanks to you both. All right thank you again. So at the November 18th meeting we walked through each of the principles for reviewing the HIE plan and the staff assessment. I won't repeat that assessment itself but I want to note for board members and for others on the phone that those slides are attached at the end of the slide deck for your reference and those are posted to the website if you'd like to re-review those. None of the staff assessment has changed as a result of the changes that DIGA made in the resubmission. I do want to quickly remind us of the principles themselves though which can be summarized as alignment with statute the first and second principles you see here whether the HIE plan meets the the goals of other recent relevant legislation and whether the HIE plan incorporates national best practices and stakeholder input. And for the connectivity criteria we use two principles for the board then we'll review focusing on alignment with HIE plan goals and on the clarity of the criteria themselves since these are really an operational tool. Lastly I'll review the public comment before I make a staff recommendation. We received three public comments on the HIE plan and connectivity criteria. Two of those were verbal comments at the November 18th meeting and those were on the role of V hi data in supporting contact tracing related to COVID-19 and on sharing sensitive data when it's not originating with the so-called part two provider. We also received one written comment during the special public comment period from by state primary care association in support of the updated plan. So given the original staff assessment presented on the 18th the changes in the resubmission to address issues raised by the board in their discussions on November 18th and 25th and the comments that we received from members of the public staff have two recommendations. First to approve the 2020 update to the health information exchange strategic plan as resubmitted on December 1st and second to approve the 2021 connectivity criteria as submitted in the 2020 update to the HIE strategic plan on December 1st noting that there were not changes to the connectivity criteria between the two versions. Thank you Sarah. Are there questions from the board for Sarah. A question for our legal counsel. Would this need to be in the form of one motion or two. I would recommend two. Okay. Before I ask a member of the board to make a motion is there any member of the public that wishes to make any further public comment. And I see that Mort Wasserman has his hand up. Hi. I just have a question about price transparency and its relationship to the health information exchange. From my understanding HIE is based on informatics standards and I've not been able to find any mention of cost or price in those standards. It's a very clinically oriented tool to convey information about patients from one clinician to another. And because it has that it also has the potential for one to extract information about it for health services investigations. But I don't understand that there's even a place to put dollars in the nuts and bolts the information the data if you will that actually go to the exchange. So my question is is there. Oh this is Emily is it okay for me to answer. Sarah did you want to. I was hoping that that I would could punt to you Emily. My understanding initially was was the same as yours that Emily Emily and board member Pellum kind of helped me helped me understand how this could be relevant in particular to the new federal interoperability rule. So I'm going to let Emily take it away because I know she'll do a much better job of explaining it. Well I think more it is completely correct in his definition of what the Vermont health information exchange does as a data tool which aggregates health data for multiple purposes. And so what we're talking about with the price transparency rule is that it together with new rules from the Office of the National Coordinator and the Center for Medicare and Medicaid Services which call for actors like health information exchanges to open up data together working together those new rules may result in IT developers who develop applications for our phones to pull together different data processes. They might pull clinical data for health information and they might pull price transparency information thanks to that new price transparency rule presenting together in one application for a person to understand both their personal health record and the cost of potential services and services that they've already received. So that's that's our guess at what might happen. But so we're pulling together all this information to inform how we might you know develop our strategic plan or make program decisions going forward based on the availability of data to individuals on their phones. Does that make sense. Yeah but it sounds like a really big stretch. That's all just because they have to get the price information or cost information and goodness knows those things are pretty strange from one place to another from somewhere. They get them directly from the providers. Most practicing clinicians have no idea what is being charged when they submit when they have a patient encounter. So it just sounds like there's a lot of groundwork to be done and I was curious why it made its way into something that was a strategic plan for the HIE. That's all. But yeah that's a good answer. I think if you look at the change the change that was made to the plan in this area more you'll see that it's really focused on what kind of outside actors or third parties might be interested in doing as this develops in you know nationally as as the price transparency rule goes into effect as well as the interoperability rule. So it's less the focus is less on what Vermont might do through the HIE and more on kind of the national perspective. Got it. Thank you. Happy to follow up on that more though if after if after you know thinking about what you heard today you have more questions. Okay thanks. Thank you. Is there any additional public comment hearing none would a board member wish to make a motion? I can make a motion. This is Robin. I I move that we approve the 2020 update to the health information exchange strategic plan as resubmitted on December 1st. Is there a second? Second. It's been moved and seconded to approve the 2020 update to the health information exchange strategic plan as resubmitted on December 1st. Is there further board discussion? Hearing none all those in favor of the motion signify by saying aye. Aye. Those opposed signify by saying nay. Let the record show that the motion carried unanimously. Would a board member wish to make a second motion? Sure. I move that we approve the 2021 connectivity criteria as submitted in the 2020 update to the health information exchange strategic plan on December 1st. Is there a second? Second. So it's been moved and seconded to approve the 2021 connectivity criteria as submitted in the 2020 update to the health information exchange strategic plan on December 1st. Is there a further board discussion? If not all those in favor of the motion signify by saying aye. Aye. Any opposed signify by saying nay. Let the record show that the motion carried unanimously. Thank you Emily. Thank you Sarah. Thank you very much. So next we're going to move on to a discussion on the ACO financial results and I'm going to call on Sarah Lindberg to tee that up and introduce the panel. Sounds good. I'm just going to wait for the slides to pop up. Yep Sarah it's Michelle. I'm working on that right now. Can you all see my screen? Good afternoon. We can yes. I can everybody probably can. Got to love the rural internet. So hi my name is Sarah Lindberg. I work for the Green Mountain Care Board and head up our analytical team and I'm here to kick off some findings for the ACO financial results for calendar year 2019. I will talk about our Medicare program and I'll be followed by our partners over at DEVA who administer the Medicaid program with the ACO and that will be Alicia Cooper and Corey Gustafson. From Blue Cross Blue Shield we will have Grace Gilbert Davis to talk about their results and we'll wrap up with Tom Boris from One Care Vermont. Please keep in mind that these are the financial results for the ACO program in 2019. Later on you'll be hearing about the all-payer model results to date for calendar year 2019. Those are broader results for all Vermont residents. These are associated with people attributed to the ACO so this is a much narrower group of people. So with that we can advance to the Medicare financial performance result. So this is blatantly stolen from our partners over at DEVA to try and help demonstrate how the risk corridor works for Medicare. So the dashed red line in the middle shows what the financial target ended up being for 2019 also known as the benchmark and that was $496 million. The risk around that the total risk is a symmetric corridor and in 2019 it was a 5% corridor. So to the left in purple you would see the potential savings of which the ACO share the 100% and that was $24.8 million. So if the total cost of care ends up coming in less so they spent less on the people attributed to the ACO they would save and up to a maximum amount of just under $25 million. Similarly there's a lost corridor on the upside so if spending ends up being in excess of that target that's the ACO's responsibility. So if you go to the next slide the ACO performed in the savings corridor so the total cost of care for their performance ended up at $484 million. So that resulted in savings of $11.1 million which included a deduction of just under $200,000 due to their quality performance and of that $6.3 million were advanced to the ACO. So 57% of those savings they received in advance to help fund the Medicare participation in the primary care medical home program and the community health team through the blueprint as well as the SASH program. So the net value was whatever 11.1 minus 6.3 is. I took a book out of Robin Lund's pages and won't do math publicly but pardon me the reason that the advance was relatively less than it was in 2020 and even 2018 was that the way it was administered is that there it was always based on the year before and because there was a 80-20 split in the risk sharing in 2018 they were only eligible to advance 80% of that value. So in 2020 we kind of changed the methodology a little bit because the cash flow to support that program can be pretty onerous. So that is the financial results for Medicare in 2019. Any questions I can address before turning it over to our colleagues over at Diva? Any questions for Sarah? If not go ahead and turn it over to Cory and Alicia. Happily. Good afternoon everyone. This is Alicia Cooper from the Department of Vermont Health Access. I'll go ahead and kick us off. Thank you for the opportunity to come to speak with all of you today. We will be summarizing in this presentation the 2019 performance results for the Vermont Medicaid Next Generation ACO program. We'll primarily focus on the financial results but we do have some high level summary slides that will speak to some of the other results and will point you in the direction of a more comprehensive report for anyone who's interested in digging into the details. Next slide please. So this is a slide that I believe we've shown before and we wanted to just use this as a starting point to reiterate that the Vermont Medicaid Next Generation ACO program is reinforced by Diva's three priorities. These priorities are listed on the slide and they relate to value-based payments, information technology projects, and performance. The VMNG program primarily intersects with priorities one and three. It's one of the programs that allows Medicaid to be a more predictable and reliable payer partner and is probably the the largest program that Medicaid currently has for transitioning payments away from a fee-for-service construct and toward a value-based payment model. The program also allows us to focus on continual incremental programmatic and performance improvement. So not only are we looking for improvements at the program level when we're thinking about financial and quality results on a year-over-year basis, we're also thinking about ways that we as the Medicaid team, working with one care, can continue to make the program more efficient and more innovative for our Vermont Medicaid members who are touching the program. And finally this program gives us the opportunity to align with other payer programs, including the Medicare and commercial programs, and it gives us opportunities to be an innovative leader. Hopefully those also give us future opportunities for alignment. But one of the areas where the Medicaid program has been able to use the the VMNG model as a way to test new things has been in how we think about attribution. We've tried some changes to our attribution methodology over time and we'd be happy to spend a little bit more time talking about that if that's of interest later. Next slide please. Just as a reminder to everyone, the Vermont Medicaid Next Generation ACO contract term began with an original contract for the 2017 performance year, which was a one-year agreement with four optional one-year extensions. Eva and one care have used one-year extensions for each the 2018, 2019, and 2020 performance years and we're currently in the process of negotiating a final one-year extension for the 2021 performance year. Rates are renegotiated annually based on the specific attributed population that we have for each year and reconciliation may occur more frequently if necessary. Next slide. So before we move into the content I'll just note that on that prior slide there is a link at the bottom that will take you to the full 2019 VMNG results report on Diva's website. That's where you've got some more detail on all of the things that we're talking about today if you'd like to reference that further. Next slide. The first result that we wanted to highlight is that the Vermont Medicaid Next Gen program continues to grow. We have seen additional providers and communities joining the ACO network to participate in the program year over year and in this slide you can see a table of each of our performance years thus far with some estimates for a 2021 performance year as well. We've seen growth in the number of health service areas participating in each year and we're starting to level out as we look at 2020 and 2021. We've also seen some growth in the number of unique Medicaid providers who are participating with a little bit of a dip from 2020 to 2021 and we've also seen corresponding to the number of providers participating an increasing number of Medicaid members who are attributed to the program. And then the final row in this table just shows the percent change over the prior year and I think what's particularly notable and we'll talk more about this as we get further into the presentation is that going from 2018 to 2019 we saw some really remarkable growth in the number of Medicaid members who were attributed in each year relative to one another with almost 88 percent increase happening in those two years. In 2020 and as I mentioned previously we had worked with OneCare to do a little bit of innovation around the attribution methodology used for the Medicaid NextGen program. As a result we had in combination traditional attribution methodology which was similar to what's been used since the beginning of the program and then on top of that an expanded attribution methodology that helped us bring some more Medicaid members into the ACO program that using traditional attribution approaches that align more closely with the Medicare approach would not have been considered eligible for attribution otherwise. So that is something that we are continuing to employ as we think about a 2021 performance year. Alicia can I ask you a question on this slide? Certainly. So I'm just curious about the jump in the attributed members whether that there's also a tie to an increase of people on the Medicaid program or is it strictly just changes in numbers of participating providers? It primarily relates to the numbers of participating providers because when we're looking at attribution in particular the traditional attribution which is what we had for both 2018 and 2019 we're looking at historic primary care utilization as the basis for that kind of attribution relationship. So even if we have more recent increases in the overall Medicaid population we wouldn't have been picking them up using that historic information were it not for the significant change in the provider participation that we saw from year to year. We do certainly notice that as we have a larger Medicaid population overall there are more individuals that can then potentially be identified because of their historic utilization and now with the expanded attribution methodology we're also identifying individuals that can be attributed even if they don't necessarily have those historic primary care relationships and those are individuals who might be brand new to Medicaid who we wouldn't have historic claims for and so there's I think a little bit of both but in 2019 in particular where we saw that significant growth that was largely attributable to an increase in provider participation. And in Vermonters come and go off of Medicaid depending upon their life circumstances is this just a total head count or is a weighted average head count or how do these numbers get calculated? So these numbers are what we use at the beginning of each performance year and we would consider this the maximum number of members that could be attributed to the ACO as of January 1st of that year. To your point we do see members who are potentially losing Medicaid eligibility during the course of a performance year and if they fully lose eligibility during the year we would cease making payments to the ACO on behalf of those individuals and we would cease counting any claims expenditure for those individuals beyond a point in time which they were no longer full Medicaid benefits eligible. We do allow members to come back in though so if someone was identified as being attributed for that January 1st period in time they lose coverage for a couple of months during the year and then they regain their coverage they're considered part of the attribution for all months for which they have Medicaid eligibility. If a Vermonter became eligible for the Medicaid program say at the end of January beginning of February and we're on that program for the rest of the year would they just not counted? That's correct if they became newly eligible for Medicaid at the beginning of the calendar year we wouldn't be able to identify them as part of the attribution for that calendar year they would be identified in the next year. Super thank you certainly all right next slide please So the second result we wanted to highlight relates to the financial performance and we'll have several additional more detailed slides after this. Overall ACO providers and Medicaid shared in financial accountability for health care in 2019. Diva and OneCare agreed on the price of health care services for the attributed population upfront and the actual spending for those attributed members was more than what we expected in the setting of that price because OneCare shares financial risk with Medicaid. OneCare has to pay for a portion of the spending that's over the agreed upon price. Another thing that was particularly interesting for 2019 was that for the third year in a row so now 2017, 18 and 19 we've seen providers who were receiving prospective payments spending less on expected services within their control which highlights the potential of the changing financial incentives in this model. We'll dig a little bit more into that in a moment but on the next slide I wanted to offer just a quick summary for anyone who is thinking about how the risk arrangement works in the Vermont Medicaid Next 10 program. Diva and OneCare at the beginning of the year set an agreed upon price and we can think about that agreed upon price is that green bar that says 100% and it lines up with the blue dashed line and that represents the price. Around the blue dashed line we have red and green dashed lines which correspond to the upper and lower boundaries of a 4% risk corridor which was what was in place for the 2019 performance year and you can see on this slide there's sort of a box that corresponds to each of the different scenarios for possible financial results and it describes the different incentives and protections that are at play and why we have this risk corridor in the first place. So for any expenditure that would be above the risk corridor so above that blue line and if we think about the blue line to the red line that would be what's described in the yellow box. The ACO network is bearing full accountability for financial performance within that range. This creates an incentive to moderate costs and keep them as close as possible to that agreed upon price. However if financial expenditure goes above and beyond even that risk corridor so above the red dashed line Diva is going to bear full accountability for any performance that's in excess of the risk corridor. This is an important protection for providers. It allows them to change the way that they're delivering care but it also protects against potentially catastrophic losses that could impact the ability of providers to participate in this kind of agreement year over year. Similarly on the the other side of the equation between the blue and green dashed lines anything in there is an amount of money that the ACO network would be entitled to retain if their financial performance was less than 100% of the agreed upon price which again is the incentive to be efficient with resources but anything below the green dashed line and outside of that risk corridor is returned to Diva which creates an incentive to spend money efficiently but not to ration care. I think there's always the concern about there being an incentive to not provide services in the first place and so having that protection on the other side ensures that that incentive isn't in place. Next slide please. So as I mentioned Diva and OneCare agreed on the price for healthcare for the attributed population and what we observed was that spending for ACO attributed members was approximately $13.5 million more than the expected price which was overall about $203 million. Because the financial performance exceeded the agreed upon price OneCare was liable for the full amount within that 4% risk corridor so if we think back to the picture on the prior slide they would be liable for the full amount between the blue dashed line and the red dashed line and for 2019 that was approximately $8.1 million. After the application of other necessary adjustments as part of the reconciliation calculation OneCare Vermont will pay approximately $6.7 million to Diva in the reconciliation for the 2019 performance year. I think important to note here is if Diva and OneCare did not have this risk sharing arrangement the Vermont Medicaid program would pay the entirety of the amount in excess of the expected price and so this is one of those rare circumstances in which some dollars because of the risk sharing arrangement are coming back to the Medicaid program. Next slide. This figure shows specifically the 2019 financial performance in a little bit more of a breakdown. So for those who have seen this figure before hopefully the last figure was helpful orientation to what we're looking at here. Again we have the blue red and green lines at the top corresponding to the price the risk corridor around that price and then within the bar we have different segments for how much of the funding in the program was paid prospectively and you can see in 2019 that was approximately 114 million dollars and also see how much sort of within that price was paid on a fee for service basis you can see 88.5 million dollars and then in the gray box at the top we can see how much was paid fee for service above and beyond that agreed upon price and that's approximately 13.5 million dollars and so when we're comparing the expected total cost of care we're looking at the 203 million which is everything below that blue solid line and when we're looking at the actual total cost of care of about 216 million we're looking at the combination of the yellow the orange and the gray boxes all together and you can see that all of those together extend beyond that red dashed line of the risk corridor showing that financial performance was just outside. Next slide please. So we did a little bit of additional analysis with one care and our perspective actuaries to try to understand what we were seeing in 2019. One of the things that was noted previously that I think is worth highlighting again is that the providers who were paid prospectively so the providers receiving the payments in that yellow segment of the bar on the prior slide spent about 8.2 million dollars less than expected on services within their control. Conversely providers who are paid fee for service and that includes both providers inside and outside of the ACO network spent about 13.5 million dollars more than expected. This highlights how the two different changing financial incentives might impact the delivery and the cost of health care and we think that this is a particularly interesting dynamic especially since we've now observed this several years in a row with our Vermont Medicaid NextGen program that makes it worth continuing to test this model. Another important factor is that the ACO attributed population nearly doubled from 2018 to 2019. So thinking back to that first result that we highlighted that 88% year over year growth in the population was a pretty significant change and it introduced relatively more uncertainty into the rate setting process than there would have been in prior processes and that's because we're setting the rate based specifically on that attributed population and so we have a lot of new folks with information that was being brought in and assumptions that were being made about them that we were building into the rate development process for 2019. And then the third thing we would highlight is that overall utilization trends increased for the entire Medicaid enrolled population between 2017 and 2019. 2017 was the base year that we used to develop the rates for 2019 and 2019 was the performance year. But what we saw as we were looking at 2017, 2018, and 2019 to understand some of these dynamics was that utilization in 2019 was more similar than to 2018's utilization than it was to 2017 even though 2017 was the year that was used to develop the price and so that's I think just a feature of the rate development methodology that we have used and gives us some opportunities to think about modifications that we might employ in future as we think about ways to develop the rates in a more sort of consistent and predictable year over year manner. On how should we look at the first bullet with the 8.2 million less for those who paid prospectively and the 13 and a half from those who were not paid prospectively and then if you flip back to the prior slide to the total of 13.5 million because the sum of the other two would actually only show an overage of about five million and I was trying to look at the 88 million and if they overspent by 13 million which is 15 percent and then the savings were on the 114 million which I think was about a 7.6 percent savings but it doesn't tie to the total 13 and a half so just don't know where you are. So that's a really great question and I think it relates most directly to how we think about the reconciliation of the prospective payments versus the reconciliation of the fee for service payment. So as as many of you may recall one of the differences between the Medicaid program and the Medicare program is that within the prospective payment category or that yellow block we are observing what the value on a fee for service basis of the claims that come in would be compared to that 114 million that is being distributed in the form of prospective payments but we're not reconciling to that fee for service experience. Okay. And so even though we saw that the value of those claims was about eight million dollars less than the 114 million that was paid prospectively we're not recollecting that and we're not factoring it into our reconciliation calculation. And so when we think about the 13.5 million in the total picture that is almost fully apples to apples the 13.5 million that we're seeing over on the fee for service experience. And then that 13.5 we would compare against the 88 million that's a 15 percent overage. It's a 15 percent overage on the fee for service component but we think about it relative to the total and for the total I think it was closer to no I don't want to get it. Okay. I mean thanks. Certainly. 6.7 percent. Okay. Great. I think we can go to the next slide. Thank you. And this I won't spend much time on. This is more for everyone's reference but we've had fun putting these staffed bar charts together year after year and we have all three of the 2017 2018 and 2019 performance years arrayed next to each other here for your reference. There's also a box with some quick statistics for the number of Medicaid providers and members and for the total agreed upon price for each of those years. I think the key takeaway here just visually is that 2019 is a lot bigger than 2018 or 2017. We also had the risk corridor going from plus or minus three percent to plus or minus four percent and so we had a widening of the risk corridor on a much larger number. And so just you know quickly looking at the space between those red and green dashed lines each year you can see that the corridor was actually quite wide in 2019 relative to the prior years. I'm happy to dig into this further if anyone wants to but just wanted to include it so that you have it as a reference point. Next slide please. So we'll wrap up with three more high-level summary results for you and then a few concluding thoughts. The third result that we wanted to highlight was that the ACO performed well against their quality targets in 2019. One care's quality score was 95 percent on pre-selected performance measures and one care demonstrated statistically significant year over year improvement on five measures. For those who may have participated in the October 7th meeting the quality results were presented in detail then and we have linked to those if you want to dig into them in more depth. Next slide please. The ACO also extended their care coordination model to more communities and people in 2019. We've seen year over year a steady increase in the percentage of high-risk and very high-risk attributed Medicaid members who are receiving care coordination interventions under one care's advanced community care coordination model. Next slide please. And the final result that we wanted to highlight was that Diva and one care have continued to make incremental programmatic improvements. We work together to identify opportunities for improvement each year and one of the key things that we focused on in 2019 was testing an expanded attribution methodology in the St. Johnsbury community based on Medicaid members place of residence rather than their historic primary care utilization. This really was the foundation for broader thinking about attribution methodology changes that we implemented statewide in 2020 and that we are continuing to implement in 2021. Next slide please. So to conclude we just wanted to highlight a few of what we see as the benefits and opportunities for the Vermont Medicaid next generation program from the Diva perspective. First the VMNG program has given Vermont Medicaid more certainty in budgeting than it would have had absent this arrangement for the last several years and that's certainly a benefit to how we think about our program and planning for the future each year. The program also allows for more revenue predictability for the Medicaid providers who are participating in one care's network in particular those providers who are being paid prospectively. The risk corridor which we've employed each year and we've seen some modest changes to in 2019 and 2020 ensures that there are both incentives to control control costs and also protections for when actual spending is different from what we might expect. So we have kind of in combination this payment predictability and this risk sharing working together to try to build some more system stability over time. I'll reiterate that the prospective and fee for service spending patterns that we have observed in the first three years though not conclusive at this point in time definitely signal the potential of changing financial incentives and we're interested to see what that looks like as we continue to look at this program for the next several years. Throughout the implementation of the VMNG program we have seen incremental improvements in quality performance for our Medicaid population and changes in the delivery of and coordination of care. And finally we think that the opportunity to continue testing this model and to continue improving how we think about our rate setting methodology to allow for additional predictability in the future are things that we're particularly excited about in in thinking about our 2021 performance year and then potentially another contract or series of contract terms that would follow after this one. I will stop there and happy to take any additional questions that folks might have at this point in time. Do board members have additional questions? I have a couple. Go ahead Jess. Thank you so much Alicia. Appreciate it as always. Could you go to slide 15 for a second? So just looking at this and hearing about the relative success of fixed payment over fee for service in terms of the total cost of care results that you had. I'm wondering if you look back in 2017 a greater proportion of the payments were actually fixed payment and it looks like over time the proportion of fixed payments is actually declining or stagnating. I haven't done the actual calculations. This is just kind of a quick visual look. But I'm wondering if you could speak a little bit to the desire to move more of the reimbursement into fixed payment. What are the services that are currently being paid fee for service? Who are the providers that are currently being paid fee for service? And given the successes in fixed payment, what is the goal for 2021? What is the proportion going to look like in 2021 and who's getting the fee for service? Can you just talk a little bit more about that? Certainly. So your observation is correct. We have seen a little bit of a shifting in the proportions from the beginning of the program to more recent years. I think in the first year it was approximately a one-third, two- third split for the fee for service and prospective payments respectively. I think right now we're a little bit closer to about 45%, 55%. And so I'd say I would certainly welcome input from OneCare as well on this discussion because a lot of the split is really being driven by which providers in the network are electing to be paid on a prospective basis and then the prospective payments that go from Diva to OneCare correspond fairly closely to how those providers are then going to be paid prospectively by OneCare. What we've seen in the first several program years is that it's largely the hospitals that are being paid prospectively. We've also seen with OneCare's implementation of their CPR pilot a number of larger independent practices that have been moving into the space of being paid on a prospective basis, which I think is a great trend and definitely represents some opportunity as we continue to move forward in the program. The I think the decision to be paid prospectively or continue to be paid on a fee for service basis is largely something that is determined between OneCare and their provider networks and their contracting processes and so I would certainly defer to OneCare on the details there. I think another thing that we would say is that while we would absolutely love to see some more movement away from fee for service and toward prospective payments there will probably always be some need to have a portion of the total price be allocated to fee for service expenditure because our members have complete freedom of choice in where they receive services and you know for instance a member who's attributed might need more specialized care at Boston Children's Hospital or something like that. Boston Children's Hospital is out of state and doesn't necessarily have a different type of payment arrangement in place with OneCare so we would continue to pay them as we otherwise would if it's the Medicaid program but then any expenditure that was accrued there for an attributed member would be counted as we're calculating this actual total cost of care for the attributed population and so we'll always have some providers who are outside of the ACO network including providers who are out of state and those providers will always be paid under I guess regular Medicaid reimbursement methodologies whatever those look like at the time. Okay, can you look back to slide 14 actually? Okay, I guess my question was around the last bullet point overall utilization trends increased for the entire Medicaid enrolled population between 17 and 19 and I'm wondering if you looked at the difference between the ACO attributed population and the rest of the population to ascertain the difference in the growth rates overall they both grew did they grow at the same rate? I know that we did have some analysis that was looking at the comparison but I don't remember the results offhand so if it would be all right I can I can coordinate with some folks on my end and we can try to get that information to you. Okay, that'd be really helpful. And then my last question was on slide 17 and this was around the high-risk and very high-risk Medicaid members of receiving more care coordination I'm just wondering has there been has Diva done any impact study of having that increased care coordination how that's affected that populations either quality outcomes or cost total cost of care growth you know seeing the impact of this increased care coordination has there been any study on that or evaluation of that? Unfortunately at this point we've not yet been able to tackle that specific question but but I agree that that is a fantastic analysis idea and we'll we'll convey that back to the rest of the team. Okay, thank you for your answers. Other questions from the board? Hi this is Robin I just had really just an observation which is I'm sure this has probably gotten more attention in legislative circles but I do think it's interesting that in addition to providing more certainty for providers that are receiving fixed payments that the program has also given the Medicaid program as a whole more certainty in budgeting. When I worked at the legislature which is now getting to be inch in history you know it was not uncommon to have ten to thirty million dollar Medicaid shortfalls and it seems like I certainly not that I'm following the blow-by-blow in the Medicaid budget these days but I haven't been hearing those sorts of numbers so I think that's a very promising finding as well. Yeah Chair Mullen can I speak to the to Robin's point and thank her for the comment because it is absolutely both to the payer and the provider a reduction in volatility in terms of utilization and you know also caseload of course for the payer side but reducing that variability year over year is a is is I would say a clear win for us definitely 19 those dollars that come back to the Medicaid program will obviously go into the Medicaid program in some way shape or form in the coming months year so that is other dollars that won't be necessitated. I think that our efforts around getting more into value-based payments really speak to that as well because that I mean it as Alicia referenced we're probably never going to get to a hundred percent and in fact when we first in 2017 considered the program said we'd love to be a hundred percent value-based payments and realize pretty quickly there needed to be some dollars outside but I would to board member use the first comments about the fee-for-service versus the the prospective payment that that you know the overages you know there is that there is analysis being done and has been done about where is that overspend and and in in large part it is those you know non part of the of the network providers a great example is Children's Hospital and other providers that that there are some in Vermont that could be but aren't and so we continue to to see that benefit so we really are I would say to you know I feel like we'll move away from Diva here in a second but I will say this other takeaway is is we have now these three years of results and we're starting to see these trends a trend doesn't mean a you know a certainty by any stretch but it does put us in a position as you all know letters from this federal government pointing in the direction of value-based care and increased focus on value-based purchasing puts Vermont we already were considered a national leader but it really puts us in a good spot to give feedback to the federal government of what works and what doesn't work and our you know our our activity to allow the you know the prospectively paid to not do a reconciliation with those and I know the board members are aware of this but to not do a reconciliation on those prospective payments with the providers is a is a you know widely regarded as a real positive as opposed to how the medicare program functions where they're prospectively paid and then they go the you know there's a reconciliation on those prospective payments which to me just adds a level of administrative burden so you know we're we think value-based payments changes in sense as we think that it can produce alignment in the in the delivery system something we want to see evolution in and but but thanks for the point board member lunch that that reduction in volatility and predictability in the dollars flowing through the health care system is really something we think is good for all sides. Thank you Commissioner Robin did you have other questions or comments. No I think everyone beat me to the punch so I'm good thank you. Is there any other questions from board members. Yeah I I have one just beat me to the first one you know right on the money but I'm just wondering kind of over time you know as as Diva went into the legislature for the 2021 budget session they specifically said that reimbursement rates wouldn't be raised except for where they were federally mandated and so I'm just wondering about the relationship over time between fee for service and fixed prospective payments relative to reimbursement rates. I would think that if reimbursement rates for fee for service were constrained that might push more people into or more providers into fixed prospective payment arrangements but I'm wondering if you have any insight into that dynamic and the tension in that relationship given the three years you have under your belt. Yeah it's an excellent it's an excellent column or strand of thought to apply to this I mean you know the long term vision is to get away from using the fee for service system as a backbone for what we put into the healthcare system that would be a great place to get to. I don't know that we get there you know in the next two years but it's it's something I think we aspire to and I think we can we've started to think about it with more reality. I think one of the point you're one of the points you're making though and intentionally or not that there is a point about if the federal government and this is kind of what I was getting at with the point about the federal government highlighting value-based purchasing as a and value-based care as a priority there's at some point along the way it is possible that even the federal government drives towards I'm just going to use an analogy here to make it simple for everyone that the weather inside value-based arrangement is better than the weather outside there we've already seen bits of this as an execute executed by the federal government but it's something we're also considering. I don't I don't have you know here's the timeline or here's exactly how but it is something to your point I think member Helen that you know if you really want to create incentive you want to make something look better in another place and less good in it in the fee-for-service realm so you know those those different strands come together to have us certainly thinking about how do we create the incentive that the that the value-based model is is a better system for the providers because as Alicia said it really has been the choice of the providers in their agreements with the with the ACO of whether or not they are taking perspective well it it might make me feel more kindly about the cost shift you know if it was fee-for-service did kind of a lag behind fixed prospective payments and and pushing more people into value-based uh based payments just because of the dynamics of the relationship between the two. Yeah I understand is it with this is a a long a long time developed healthcare system we're engaging in reforming and I know reform has been going on for a long time but it's a I understand the point it's it's not lost on us either. Did you have other questions or comments Tom? Uh no I'm good Jess hit that first one right on the nose I was had it all noted out here to ask and uh she went precisely where I was having on that first question. Was that the question about the why the providers or the patients kind of in the services or and why the the drop in perspective? Yeah it was it was a question on proportionality over the three years and and fixed prospective payments seeming to um lose it you know even though they had growth they're losing a share of the total pie um and I thought the answer was a good one. Yeah good and Kevin I just to uh hit on something that you asked about the populations like the Medicaid population over time so in that chart of 17, 18 and 19 um we had had we've been experiencing over those years decline in Medicaid population so the growth goes against um you know reductions in Medicaid enrollments about well four 17 minus three percent 18 and minus three percent 19 we are obviously with the uh we've gotten the uh pandemic yeah we got the pandemic bump in f-map but that comes along with a uh you know continuous coverage maintenance of effort requirement and so we aren't redetermining anyone right now and people are staying on Medicaid so that sort of revolving door that you mentioned it really is a one-way door right now people are coming in so we don't have a good sense of our numbers right this second but we have seen it growth this year those previous years though it had been a decline so those those um to the attributed lives and the total Medicaid enrollment had been going in different directions. What kind of assumptions did you use commissioner um for the coming year um given the fact that it's going to take a while for vaccines to be distributed? It's such a great question we don't we are working on you mean the assumptions that achieving a 2021 contract agreement? Yes. It's a it's just a good question right now we're in negotiate contract negotiations and this is obviously that's a very big piece of the puzzle um as you know Medicare has already started to consider what it what will what 2021 will look like in terms of all kinds of different aspects but as far as assumptions on utilization it's a I don't think we've arrived at anything um sort of public ready at this point. I didn't know if you had a better uh forecast than what we have seen but it's it's such a really uh look into a crystal ball and such a crap game it's you know just yeah I mean the the the interesting point is that in 2019 with that expanding basically doubling of the population and and a real large list of new providers joining um the uh the program we saw that elevation um in utilization and and the exceeding of the estimated total cost of care um you know there's an assumption that as you shut down your system for an extended period of time in 2020 that you'll be producing uh you know a less than the estimated total cost of care we have seen healthcare balanced back so it really is a matter of how do you deal with that um segment of time where there was really very little going on because we really hadn't hit we were in a a medium phase of uh cases and we didn't see a ton of hospitalization so um due to the pandemic but what we really did the the system did shut down for itself to pair in case we did have a a surge in cases so yeah you um TBD is really the answer Any other questions? Yeah Kevin I just have one more quick one that came to mind um I'm kind of looking down the road let's assume that um uh yeah as we saw and or you saw in 2019 that the overages were in fee for service and the fixed perspective payment they were savings and you know let's assume that that that is the reality that uh if the system is working as those who hold for felt you know uh for health care reform uh expect that's theory and it's working how do you um so so Diva then developed some savings um at least in part of their Medicaid portfolio how do you keep that savings uh in the Medicaid system to reward the the fixed perspective payment folks um for their good job and not let that money or the general fund portion of that money get siphoned off by the legislature to go somewhere else you're on mute you're on mute I jeez I wish I had my t-shirt on that says you're on mute I hear that twice a meeting I'm surprised that I'm the one this time um it's a good question like every one of these questions it's a it's a great question I um you know I believe that the legislation it depends on the legislature first of all right who's there and I mean I think that the legislature has been really great at understanding uh where we're trying to go with this program I think that um they've also um I mean there just is a reality of state budgeting I do not I probably do not have to to tell you that but I um I think it's an ongoing conversation I think that this program is far from baked I mean I think we really wanted to evolve I think that diva has seen itself and Medicaid the Medicaid program in its contract remember this is just one piece and that's we have to get to the other pieces of the puzzle but this program is just one piece um I think that the you know we we continue to try to get our programs to look more and more the same and as we do that then the savings really start to accrue because the administrative burden of having even though we're we're in the same vein here across commercial across and um and the government payers they aren't exactly the same so um I know your question is about uh any kinds of savings being preserved to you know go into the health care system and create a greater balance between government and commercial payers I think that's the the sort of thrust of the question I think it's a great question and something um we're clearly interested in um as we and and kind of get off that hamster wheel of how much money do we have and then what do we do and um it really by the way it is you know from the CMS administrator that's the current CMS administrator it's really the justification for moving towards value-based payments at the federal level is so that Medicaid programs aren't necessarily um just saying well how much do we have and that's how much we distribute um accordingly so um I know it's not a it's not a complete answer but it it it respects the the idea of the question uh member Pell okay any other questions if not let's proceed to the next panelist are you available you may have to unmute I'm not sure if you've dialed in Grace it looks like you're unmuted are you also dialed in looking to see if anyone else is on from Blue Cross just confirming we're not having connectivity issues I did hear the governor's press conference had some issues with teams yesterday so I'm not sure if we're running into that again I seem to be the culprit every time I present we have some sort of issue um so Grace are you able to to speak or anyone from Blue Cross for that matter just to see if we can get through it looks like Rebecca Copans from Blue Cross is also on can you hear us Rebecca this is Sarah teach out hi Sarah hi there I'm texting Grace to see if she's available um I don't think you would want me to give this presentation because I honestly it's not an area I have prepared at all um you know I could read the slides to you but I don't think that's what you're looking for okay it looks like Rebecca can hear us also but she can't get through either maybe that's the issue that Grace is running into um so why don't I have it okay perfect do you mind if we have Tom let's make sure we can hear Tom Boris from OneCare Tom are you able to get through well uh can you hear me yeah yeah all right then maybe what I'll do is I'll just pivot we'll do OneCare only has a couple of slides but we'll see if we can get Grace back and then we can kind of go backwards if that's okay with everyone sounds like a good plan okay all right thank you Tom let me just advance to your slides hang on just one second thanks so hi everyone Tom Boris Vice President of Finance for OneCare Vermont I'm leaving you with really just two kind of simple thoughts I think we're important um the first is really just to say that this value-based care stuff in the settlements are extremely complex and I think um for the benefit of us all to really explain what it's doing is important here so to me this is this is all value-based care at work and the slide that I prepare has two lines the blue line is our targeted growth over time I use the three and a half percent compounded is to stay consistent here but if this is the goal of healthcare cost growth while these settlements feel really complicated and we have things like risk corridors and sharing terms and mix of fixed payments and fee for service really what these settlements are our reconciliation is back to what we hope is this stable trend over time and this is how we actually despite the complexities of it build stability into the healthcare system across the state and I just think that's a really important factor for about this board but also members of the public listening as well to understand that when we have when we set these total cost of care targets it gives all of us the state the ability to dictate what that blue line looks like and at the end of the year when we settled to it we're reconciling to a more stable and predictable healthcare cost curve which we hope benefits from us all this is an oversimplified example to prove that point you do have other factors that are important in it overall but I did want to start with that and show this visual that I often think about but don't really have an opportunity to share very often so I took the chance today next slide and then this slide here is designed to just answer the question what happens to the shared savings if earned and then how does one care fund shared savings losses rather if owed back to the payers so all of the contractual relationships are directly between one care and the corresponding payers so medicare from on medicaid diva for example but then we have contracts with our provider network to either receive or fund any of the losses that they're owes or receives from those payers and we have modified the way that we do this over time in 2019 which is the year that you just heard about we took those overall targets broke them down by hsa and then measured each hsa independently very complicated exercise to do that which means that even though in medicaid uh or i'll use medicare medicare for example we are in shared savings not every community uh got some of those shared savings based on their individual performance where we're headed in 2020 and beyond is a different model that's a much more system focused model where if there are shared savings earned everyone gets a piece of those uh dollars and if there are losses owed everyone contributes so we all uh hopefully rise together over time next we have the sharing model within each hsa so we really always broke down spend by the hospital or health service area uh through 2020 the hospital was identifies the sole risk-bearing entity for their hsa and as we evolve into 2021 we are spreading accountability more broadly to include all attributing providers spoke about this in our budget testimony but i just want to make sure to cover that as well here as just to say that we're broadening those who have financial stake in the outcomes of these programs in spirit of really having rallied effort behind driving positive performance and success long term under a value-based care paradigm and that's what i had prepared i do have some thoughts on the medicaid fixed payment split over time if you're interested we would be sure sure so the the change in the split from being more heavily fixed payment and less substantially fee for service uh is driven largely by our network growth and what has caused the shift to move back towards a more 50-50 split is the inclusion of attributing providers that are not receiving a fixed payment so an example would be an fqhc as you add the fqhc's and all that fqhc spend is now included in the total cost of care that largely wasn't before because if you attribute to a hospital primary care you're not very likely to go to an fqhc but as we've included those fqhc's into the network over time all that's then becomes part of the accountability and it's all still classified as a fee for service payment so that's the reason you've seen that split or that change in the split over time um and it's i think an opportunity for us to explore some additional fixed payment programs over over the next few years would there have to be changes at the federal level that would allow that to occur tom or can we do that now i don't believe so but i'm not the expert on the federal regulations for fqhc billing diva might have some thoughts on that as well it's an area that we've explored a little bit but it's something i think we have an eye on downstream okay questions or comments for tom hearing none let's see if we can uh we can hear grace grace are you on can you folks hear me now yes well okay i'm so sorry i had no idea what happened but sincere apologies so um for the record my name is grace gover davis and i am just approaching my eighth week in the position of corporate director for health care reform for book cross for shield of vermont and i'm delighted to be here today to discuss the financial outcomes of um our 2018 relationship with one care vermont next slide please so because i come to you with 30 years working on the provider side and only seven and a half weeks working on the payer side i thought it was worth just revisiting what the vision of book cross for shield is for my benefit and for yours you we truly do believe that we can build together a transformed health care system for every remonter so they receive timely high quality low-cost care and our mission is we are committed to the health of vermonters to an offending member experience and to responsibly manage the lives of the people that choose to to work with book cross for shield of vermont next slide please thank you so here's your shared this slide with you when he went through the quality outcomes i believe last month or the month before there were some great great spots with one care this year in terms of our ability to work together and to continue to find ways to improve how we work together how we share data just generally keeping the lines of communication open and being as transparent with each other as possible i think there's a wonderful sense of collaboration between the two organizations and you know as someone with fresh eyes i it was refreshing to to see that and to experience it over the past number of weeks and to understand that the two organizations have worked together to successfully implement a commercial prospective payment system that is working that thing said there have been some challenges and these come as no surprise to anybody but just connecting you know the current quality metrics to the actual impact of one care vermont on our members we're you know we're working already with the 2021 contract discussions around putting together a quality improvement work plan as a solution to this because we do want to be able in the future to clearly demonstrate that members one care members who are attributed to one care you know are seeing are getting better care at a lower cost and obviously like everybody COVID-19 has disrupted just about everything and that includes you know our ability to to engage in new qi initiatives next slide please so these again these results are for small group and individual members so our target was 557 per member per month and the actual spend did exceed that by 6.5 million which is net of you know the member cost share so in a 50-50 risk share which was the the arrangement one care would have owed blue cross for shed vermont approximately you know three and a quarter million dollars but there were some data challenges prior to my onboarding with the organization that I understand impacted blue cross's ability to get data to one care in a timely fashion and so as a result of that we agreed to shift to a shared savings arrangement only for 2019 next slide please so to summarize after normalizing the results of the qhp population and to better understand normalizing I'm not an actuarial and it's not in my plans to ever be one but as I understand it the way we did this was to limit the non are we getting a um some kind of take back is not muted that they could mute themselves it would be helpful because there is a little bit of an echo but we can still understand you grace okay all right um again normalizing we limit the non one care vermont cohort to a population that's attributed to non one care vermont providers and we exclude members from that cohort with zero claims we also normalize the medical spends by focusing on utilization analysis by inpatient outpatient and profession and professional so after this normalizing the attributed population results are six point six percent above target our analysis indicates that roughly two percent of this overage is related to adjustments to to the premiums approved premiums by the cream out and care board and that the remaining four percent is unique to one care vermont attributed members and we'll talk about that a little bit more in the next slide the data challenges that I mentioned in the during the aforementioned slide that don't seem to have affected these outcomes next slide please so there were three dynamics that drove the overage that we spent considerable time analyzing this data so there's significantly more enm and mental health substance use disorder visits than we had anticipated interestingly higher use of urgent care visits which did not equate to a decrease in emergency department visits and actually there was a slight uptick in the cost of emergency department visits that's a deeper dive that we'll be working on and then we found that the PT services that were utilized were either more costly and or more intense and of course if they're more intense they're going to be more costly there were some downstream effects one kid adolescents who are attributed to one care received well care visits encounters at a much higher rate which you know in our current environment I think this is a good sign it's a good trend but otherwise additional office visits are not yet showing or translating into reduced gaps in care the urgent care use as I mentioned did not reduce ER utilization one of the things we are going to do after reviewing these results with the one care team is we are going to look at the data across HSAs because we know that primary access to primary care providers in the rural settings in Vermont can be challenging there's only so many acute visits that are left open in a provider's morning and afternoon block and once those are filled in the morning and generally you know by 8 30 those those visits are filled those acute visits are filled then either the patient will make the determination or the provider will encourage them to seek out you know urgent care so we're going to be looking across to understand better why we didn't see a decrease in the visits next slide please we really enjoy working with one care it's a great team they're passionate about the work that they're doing we know that we're all on a learning curve so in after we discuss these findings we're going to dig deeper into the data so how much more of the office-based care was proactive and preventative that's a question that was asked we don't have an answer for that yet again how does urgent care use differ across the regions and we need to understand as they increase physical therapy expense tied to unit costs or is it just that the services are are more intense you know that that injuries necessitated more intense and prolonged care that is what i have for you i am here to answer any questions that i can but i will be honest with you i'm i'm not well versed enough to probably provide a lot of specifics but we will be very timely and follow up with any questions that i cannot answer and you're on mute if you were talking i need kori's t-shirt so grace what i was saying is that it's interesting that your citing increased p-t expenses because we repeatedly have received public comments from providers in the p-t community that they're very frustrated with the lack of any increases in payments from commercial providers and so it'll be be interesting when you do that deeper dive to get those results absolutely i mean we also need to understand you know where we're in lives of difference are these hospital employees physical therapists are the or are these private practice physical therapists that'll be a key component to it with that are the questions of grace from the board um thank you grace and nice to virtually meet you anyway uh welcome aboard thank you very much so a question about a couple questions one is about scale we know that scale is such an important component of the model's success and so i'm wondering what role blue cross blue shield can play in increasing scale i know we we've had conversations around the self-insured market and all that but i guess given that this is we're talking about the small small group and individual market here i'm wondering what percentage of patient subscribers don't have who are in this market in the exchange market don't have a primary care provider and what role blue cross blue shield could play to make sure that they are uh assigned or have you know incentivized encouraged to become to you know to have a primary care provider and then therefore maybe be more likely to be attributed and included in the populations yes that's a great question i know that there is work um and i can't be i can't be specific because in the i don't know how many meetings i've had in the seven and a half weeks many many meetings there has been discussion about how do we reach out to those individuals who have not been in for at least an annual physical um and how do we um how do i identify who they are how do we identify if they have a primary care provider and if not how do they get a primary care provider i it's a work in progress and something that you know we are committed to helping um increase scales most certainly both in you know the small groups and in large groups can i follow up on that jess of course yeah great so are there any incentives or disincentives that uh are offered um to try to make sure that that primary care visit occurs you know um for your mom that's an excellent question and and i can't answer that not even from the provider side um so i will i will have to find that out okay great thank you sorry jess oh no no worries that was sort of what i was getting at anyway so that's great um my second question is around so it's you know the spend was greater than the target but some of as you did a deep dive it was interesting to see that some of the greater expense was in areas that we would like to see greater expense right we want to see more well care visits we want to see patients that have mental health and substance abuse um concerns seeking treatment being able to receive the treatment that they need so i'm wondering um this goes back to questions that came up in the hearing how much work does blue cross blue shield do in thinking about uh high value care and low value care right high value care being the care that we know uh gives you a bank for the buck high rate of return on that investment low value care being care that's delivered that may or may not increase a patient's health or actually may harm a patient depending upon what the care is so some of this looks like high value care that we would hope patients would receive um so i'm wondering if you've unpacked a little bit of that obviously if we start paying uh providers differently in a way that incentivizes high value care and disincentivizes low value care patient outcome should improve and hopefully costs will go down but in the interim we may be seeing a bump up in expense if there's just more high value care happening that hadn't been happening before so how do you think about that again that is something that i will have to follow up on i truly wish i could answer that question but um it says time i can't okay so a timely follow-up within 24 hours you can have more than 24 hours it's it's a complicated question you know a year from now when you're asking these questions it will not be an issue no worries other questions i have a question if uh you're done jess i'm done thank you um and i guess it's really more of a statement um so on page 24 when you're talking about the performance you attribute 2.3 percent of the overage to premium adjustments filed in the qualified health uh plan premium process so that led me to go back to um the 2019 rate filing and what i found that uh was linked to the 2.3 percent was a reduction that we made related to assumptions about association health plan uh implementation um and to quote from our decision um the the reentry of AHPs into the insurance market was on the horizon when blue well before blue cross developed its rate blue cross chose not to include any potential rate impact in its initial may 11th 2018 filing even though it had already begun discussions with a number of associations interested in offering AHPs in the Vermont market um but then five days prior to hearing blue cross amended its filing to include what it projected to be a significant significant rate impact from the migration of the small group population to the association health plans um and what we basically found when we analyzed the arguments and data that blue cross provided was that blue cross had not proven its case in relationship to the migration of association health plans and so that combined with the fact that when we look to what to what actually happened which was that blue cross was actively marketing association health plans to small group members to pull them out of the market and into the association health plans i really don't think the statement on on uh slide 24 is factually or legally accurate i think it's really a public relations statement and so i think that for me personally i would really like to request that this slide be updated to be more accurate i think it's fine to indicate that you know blue cross didn't get everything that it asked for in in its rate filing but the reason it was not approved is because the case was not made um in addition i would also like to point out that in our 2019 decision of the aco budget the conditions on the aco related to the commercial marketplace is that the one care provide the board with an actual actuarial certification for the commercial benchmark stating that the benchmark is adequate but not excessive and we did receive such an actuarial certification so um i think really part of what uh in looking at the benchmarks versus the premiums we have purposely left open given that we're deciding the premiums in july and deciding the um aco budget in december and quite frankly the blue cross contract has never once been finalized prior to our decision making on the aco budget we leave it open for negotiation to ensure that when you get the attribution in the individual and small group market that you're able to negotiate a benchmark that reflects that population given that you have much more up-to-date information in january than certainly we all had in july so um i absolutely do not expect you to be able to respond to this grace um and i apologize that you are the messenger with no that's fine that's fine you're educating me i really just want to object to that statement on the slide and ask that it be corrected duly noted and thank you for the feedback you're welcome are there other questions or comments for grace so i think that we've been through all the uh panel am i missing anyone sarah your this is michelle you're not missing anybody great thank you so at this point i'm going to open it up for public comment or questions members of the public and uh julie wassen yes um i have a question for blue cross bluefield i'm interested in the financial results for 2019 for the blue cross one carers blue cross blue shield self-insured program and uh uh all we're also interested in the quality performance for the self-insured uh blue cross blue shield program and miss wassen i am apologetic again i will have to follow up and get that information for you thank you my pleasure okay are there other public comments or questions and i see that susan iranoff has her hand up um good afternoon mr chair the rest of the board um everyone staff so i have um one follow-up for blue cross and i just want to echo um julie wassenman's request for the um self-insured information and hope that that gets presented to the board as well um because i think it's really relevant but in the slides and in the testimony there was an indication that the square up for 2019 that there's going to be some sort of shift to it being shared savings for 2019 so my question is a little bit could we get more information on that and how would that affect a scale target attribution for the year 2019 does the board have a process for going back in time like to qualify for scale and to have been reported a scale it couldn't have been shared savings but if now it's going to be screwed up or shared savings would the scale numbers be screwed up as well and i do have questions about the other presentations but i sort of just want to take the blue cross one first well again um if you ask me these questions in a year i will be able to answer them promptly and with full knowledge i'm definitely hearing and i too am interested about the self-insured piece and so we will come back to the board with that information and as for the scale question i will have to go back to our actual aerials and find out the answer for you part of that question actually mr chair was was for the board or i don't know if you'd turn that over to mike or someone for an opinion on that but if there is a change after the fact how would the board address that mike go ahead sorry i don't want to speak for mike but i did just look at uh over lunch at the 2019 order um and the order required did not require a particular risk sharing arrangement so shared savings does count towards scale under the all-pair model agreement so i don't think the scale numbers would need to be adjusted because shared savings is allowed as part of scale but i would defer to mike i don't think there's a direct contradiction to the order itself um yeah just speaking i don't know the particulars of the shared savings arrangement but robin you're correct that the all-pair model agreement in defining a co scale qualifying initiative does not require risk if there's going to be shared savings it requires a certain percentage so i think that would be kind of the issue but i don't i don't remember the specifics of the arrangement so but will there be some sort of rec i guess what i'm wondering is does the board have a mechanism for a retrospective review if it turns out that whatever the arrangement was that was agreed to in 2019 is then changed from true up does the board um look to see if it does comply with its orders in terms yeah i don't know what what order you're you're referring to obviously we report scale to to cms cmi so it would have to be a part of that reporting any sort of true up which you know i haven't talked with the staff about so i'm not prepared to talk about it and susan you said you had other comments yeah i was um wondering and this was in something references something that commissioner gustason said and i don't know if he's still present or not um so if he is maybe he could respond directly but at the me meeting on monday he seemed to make a statement uh where there was a presentation on one care and also on the the performance improvement plan um he seemed to make a statement that would imply that where where medicare is seeming to not just want reconciliation to feed a service but actually recoup some of the prospective payments that medicare made whereas medicate is not doing that so i was just looking for a clarification like is it just the reconciliation that the commissioner is referring to or is medicare actually seeking repayments um from providers that receive perfect prospective payments value-based payments that for services that were not provided during the pandemic it's the it's the same comment i made sue about the prospective payments being reconciled against actual care delivered in the medicare program and it seems to fly um the comment i made on monday and today is it seems to fly in the face of the value of flexibility that prospective payment and the predictability of dollars available to a health care system to perform uh health care and deliver it differently um it it seems to not allow for that kind of flexibility if you're going to go back and go through an administrative exercise to to um reconcile against how much um you know prospective payment versus how much was done in a in a claims-based reconciliation okay thank you for that clarification so medicare isn't actually um reaching you know for any sort of clawback related to prospective payments during the pandemic or anything like that this is just the bookkeeping aspect well i'm not medicare or the aco but i think that you could ask the aco okay to answer that okay thank you that's it for now mr terp thank you thank you susan is there any other public comment kevin mike fisher here go ahead mike uh good afternoon um i am focused on the 29th the medicare 2019 uh the the sort of the interesting data in um the 8.2 million dollar um savings in the prospective payment um category and the 13.5 million dollar loss higher expenditures and and i i uh at least you and i had a little bit of this conversation across the table at the meab but um i i i guess i just wanted to ask this question again in a in a bit of a higher level um you know two theories one of them is proof in the pudding it's working we are seeing providers behave differently when you pay them prospectively um another possibility is that we have a uh two diff very different sets of providers out there that have maybe been pretty well sorted by the um choosing to belong or not to belong to um to the network to one care um and that those providers behave differently and that's what we're seeing here um and then i then i also i um let me see if i can get this open quickly i noted that that the the fee for service line was both in network and out of one care network and i guess i just wanted to ask i i think um i'm reading in the charts below that that is uh about evenly divided that the fee for service expenditures were are pretty evenly divided between in network and out of network um so i put all that back in in front of i'd love to hear tom's perspective on on you know what we really see going on here um or i'd also love to invite alicia if she has further comments about um so what's the theory here in response to sort of the points i put back in front of us tom or alicia i can i can speak to those briefly and welcome alicia as well but i guess in regard to the first question about whether or not providers can select to participate in the fixed payment model based on their perceived ability to do well under it um i don't think that's the case and the reason i believe that is that we've offered a fixed payment model for hospitals since really the beginning of our programs and as of uh today we have all vermont hospitals except for one um participating and accepting the fixed payment so if we saw a mix of some hospitals saying yes the fixed payment in some hospitals saying no to the fixed payment there might be some credence to what you're saying um mike but uh because everyone's jumped in and we've seen similar results at least in aggregate uh i don't think that's the case right now as for the mix of the fee for service between in network and out of network i don't have the split in front of me um 50 50 seems about right based on my recollection the important thing here is that an aco model is a population or person based spending accountability so when a primary care provider attributes a patient they become responsible for that patient's total cost of care and quality regardless of where they go so their primary care is is kind of the quarterback for their care in a lot of ways um and making their decisions in spirit of really efficient and effective health care and value-based care that naturally will include services provided both by one care providers and non-one care providers could mean that a primary care refers a patient using their best judgment to a practice or a provider that's not participating in one care there could be a bad circumstance where somebody has to be referred out of state to boston or something for a unique treatment so the the mix of fee for service in and fee for service out is just a it's just a dynamic that comes when you build these population based models that focus on healthcare costs for an individual person so tom do you have a theory as to why there's such a different outcome here between the perspective and the fee for service i do i mean i think that when you put financial incentives and probably combined with penalties i don't think one of the other is necessarily better by itself but when you put financial incentives in place it does change behavior and i can say over the past few years we've had an hsa accountability model or healthcare spending model that was very hospital focused and the hospitals were those that accepted the fixed payments and over time i've seen much more engagement from those hospitals because they have financial accountability and i think that is panning out here we've i mean i still go back to my first year at one care there was the Medicaid program was two-sided and then there was upside only for Medicare and commercial basically all we talked about was the Medicaid program that's where the attention was because that's where the financial accountability was as well so i think over the past few years we've really seen the effectiveness of financial accountability and that started with the hospital it's where it's been under the fixed payments and so just the last point then i take it the the right thing to do to deal with the over expenditure in the fee for service line is is to just get as much of that as is reasonable into a prospective payment i think that's a strategy i think coupled with that is a strategy to broaden financial accountability beyond the hospitals which is what we're trying to do in 2021 with a new risk sharing model you don't have to have a fixed payment in place but having financial accountability of some sort i think is really important as we move forward all right thank you thank you mic is there other members of the public who wish to comment seeing none i wish to thank the panel for a very informative discussion and we are now going to move on and michelle if you could stay on screen because we are going to shift to you and lindsay for an update on the all-payer model we are just gonna be one second while i reload slides here can you see my slides and does it say all-payer model update it does okay because my screen share was still showing financial and i was like this cannot be right either that or i left the same title on both slides this is entirely possible uh so uh lindsay and i are here today to talk to you about uh 2019 which is performance year two kind of interim all-payer model update i know we typically in the past have done these to the board as frequently as quarterly and i think you know just seemed a good time to really check in and see where we are in terms of finalizing some of our 2019 data um so i i will start by just kind of reminding folks you know we 2019 data that are included here are not complete we are in performance year three which is 2020 we're about to about to talk about the 2021 proposed budget from the ACO so i know we're kind of treading through three years here i'll try to keep it as clear as possible as we move forward but for the almost every point in this presentation we're talking specifically about 2019 performance year two of the all-payer model so what's that uh quick agenda for today just what we're going to talk through um we are going to talk today about the 2019 results again that we have to date um just a friendly reminder claims take a while analysis time we're working to finalize all results by the year's end for the most part but given the current state and just regular you know data delays that we have experienced in the past we could encounter some sort of reporting delays as well and also just a quick note that last week you heard about the all-payer model improvement plan um we haven't quite included any of that here in this presentation just yet i think you know to be expected as we sort of move through and start talking about future years but for this again just performance year two reporting and we'll work with our signatory partners to incorporate those improved and improvement plan objectives into future reports so with that i'm going to turn it over to Lindsay Kil and she will walk through um some of our preliminary 2019 total cost of care results so Lindsay thank you Michelle can everyone hear me okay yeah you can't great thank you so much um so as Michelle said my name is Lindsay Kil and i'm a member of the GMCB analytics team under Sarah Lindberg yep next slide Michelle thank you so before i get into some results i just want to reiterate what Michelle just said about background the results that i'm about to show are with three months of claims run out we do not consider results final until there are six months of claims run out on the books and that in with this current year 2019 there are three years for Medicaid participation in the model and two years for Medicare and commercial participation in the model next slide please so here we are comparing expenditure measures that we have at our fingertips here at the board the scale here is the proportion of total expenditures on behalf of Vermont residents so that's that 100 percent there is what we capture in our expenditure analysis expenditure analysis projections for 2019 and that's in millions so it's um it's roughly 6.5 billion dollars is the total Vermont residents spend and then in the center we have the all-payer model total cost of care for 2019 so in 2019 this represented about 46 percent of the total spending on behalf of Vermont residents and again this scale is in million so this is approximately 2.9 billion dollars and lastly all the way to the right we have one care Vermont's total cost of care based on their 2019 actual figures and in 2019 this was about 10 percent of the total spending on behalf of Vermont residents which was 637 million dollars next slide please so what this slide is showing here is going back to the same chart just giving a little bit more context the remaining 54 percent for the all-payer model total cost of care I'm sorry that that's not included in the all-payer model total cost of care and why it's different from our expenditure analysis projection are these are just some of the reasons so the all-payer model total cost of care does not include uninsured Vermont residents does not include federal employees with federal health plans workman's compensation retail pharmacy dental expenses and government health care activities which are mostly Medicaid it doesn't include long-term institutional care for commercial and Medicaid and it doesn't include skilled nursing for Medicaid and then just to kind of connect the one care Vermont total cost of care to some slides that Michelle will talk about with scale the 10 figure you see here the 637 million is on behalf of 30 percent of the Vermont population because as we know one care Vermont total cost of care is specific to their attributed lives and so in 2019 it's about 30 percent next slide please so the question that we're going to answer today is how did the per person total cost of care change from 2017 to 2019 for Vermont residents below is the equation that's used to calculate that difference and the resulting difference is it's changed 4.2 percent as a reminder the range for the all-payer model agreement is actually 3.5 percent to 4.3 so 4.2 is on the higher end of that but it is still within there and also just want to remind us all again that even though we do monitor year-over-year change our performance is assessed for growth from that first year in 2017 to through the end of the model or for right now to date so it's really about the compounding annual growth. Next slide please so on this slide we are showing the all-payer total cost of care by payer type and here I've also included some estimates for what 2019 final numbers could look like because again we need three more months of run out so that very first row is from the is a national trend on the total spend annual percent change from 2017 to 2018 that's based on the national health expenditures dataset they didn't have 2019 yet but when we do when they do we'll definitely fill it in here so that we can see how the year-over-year change looks compared Vermont compared nationally but that's it's 4.8 percent and so that's a good number to just keep in mind as we look at these rates by payer so the way that you would read this table is that for the all-payer model in 2019 with the current data that we have only three months of run out the per member per month cost is $544. We've estimated that with an additional three months of claims run out that will land somewhere between $500 and $558 per member per month in the first sorry between the first and second year we saw 4.1 percent growth and between the second and third year sorry that's a little confusing between PY1 and PY2 we are expecting a range between 5.5 percent and 7 percent to see change again that's just between one year what what we're really interested in is that overall compounded annual growth and for the all-payer model we are estimating that that could land between 4.8 percent and 5.5 percent overall and you can see the totals that's how that's exactly how you would read the rest of the chart for each of the payers so we see some big change in commercial between PY1 and PY2 that's affected their compounded annual growth so about everything else looks in line with that 4.8 percent you can go to the next slide Michelle sorry Lindsay I just want to pop in and remind folks here that there is no target for annual growth so we are only held accountable for that performance year 5 compounded growth I just want to reiterate that one more time yeah there you go so this thank you so this next slide it's just another way to look at the share of the total cost of care by payer versus the population by payer so the way that we would read this is that Medicare for example takes 44 percent of that 2.9 billion dollars for the total cost of care in terms of the dollars the expenditures but their patient population for their member months is only 27 percent so that's how we would read this chart so we can see that Medicaid has 15 percent of the total cost of care expenditures but they have 28 percent of the member months in the model and commercials more even they have 42 percent of expenditures and 45 percent of member months and next slide great so this is just going over the next step so as I've said a couple times we really want those six months of run out for final report production and that relies on data for Medicare and we anticipate that in early 2021 one consequence just you know thinking about you know the end of year five that compounded growth rate one consequence of COVID-19 is that we do expect the compounding growth through 2020 to be lower for better or for worse and also we just want to add that once we have final data for this year we will be completing more nuanced analyses on growth as in what does that look like in-state versus out-of-state and other examples so I think that that is all for me thank you so I will turn it over now and start talking just briefly about our 2019 scale targets and alignment. You've heard staff speak about this as well I know Elena and Sarah Kinsler spoke to the board about the scale warning letter so this particular set of slides does not necessarily focus on the improvements or the strategies implemented there again it's just a review of where we're at for performance or two of the model with that said so we'll start with our all-payer scale so as we know we've not met targets to date and current projections do show that continuing the results here for 2020 and 2021 all utilize the 2019 population estimates I just want to emphasize that it's very likely that these can change once we do have those updated population estimates this is something that we run into every year when we get the ACO's budget projections and are able to sort of make these analyses but I just wanted to point out that once we are able to get for example the 2020 population estimates we will update both 2020 and 2021 with those newer population estimates so right now the 8 p.m. year 3 which is what we're in now 2020 is again still using preliminary results based on attribution from payer contracts these reports become final in June the year following that's when they're submitted to CMMI so we'll have that prepared and on time for June of next year. Preliminary year 4 are utilizing results from the ACO or projections I'm sorry from the ACO that we received through their budget submission for performance year 4 of the model. Again for Medicare scale here we're missing scale targets same caveat these data utilize for 2020 and 2021 do utilize the 2019 population estimates and I'll reiterate a point that's been shared before and you know I think Sarah Lemberg has said that they know Elena and Bear Kinsler have also pointed this out you know in the past we have run some analysis specifically on Medicare providers and it was noted that even if all Medicare providers participated we would never reach scale targets that were set forth in the agreement so I know that's part of the scale discussions moving forward but again this is just sort of a look right now for for what we're what we're moving towards for performance year 3 and 4. So again discuss the scale performance of warning letter at the board meeting last week in terms of strategies the next steps the final year the model performance year 5 or 2022 will show the potential impact of these strategies that are set forth in that response next year scale report will be fine so next June we'll have a final 2020 report that report will include projected 2021 since we'll have a better idea point in time projected 2022 results will be available again once the ACO presents and submits its 2022 budget based on contract negotiations negotiations at that point in time so we're kind of always on a rolling basis here but final 2020 June 2021 is when that report will be submitted and in terms of oh I'm moving I look at me just moving on quality and population health outcomes again as Alicia pointed out earlier today we talked about this back in early October but like I'll just give a brief update of where we are in terms of the model expectations so stepping away from payer reported ACO contract quality performance and moving into all payer model quality of performance as Lindsay stated we need six months of runout to produce some of our claims level measures that are required as part of the model the most notably there are going to be HEDIS measures as a reminder the 2018 report was published in February of 2020 so while we are working to collect some of that data necessary to complete that report you have to remember that we also rely on our partners at the health department and other state agencies some of this information and we know that they have been very busy in the COVID response and so we want to respect that the possibility there for again some data delays based on what we need to populate this report and absolutely honor all the work that they're doing and so we will keep you posted as this timeframe may fluctuate based on data availability from both claims level and state partner. I also just wanted to sort of give a little preview of staff works that is planned or in progress we're looking at assessing trends over time or a way to be able to assess trends over time sort of looking at that in and out of the ACO so who are the quote unquote stares in a program so being able to sort of look at quality performance from the beginning of the all payer model to 2018 and looking at their health outcomes as they've progressed through the program because of some limitations we do know they would have to be within the same payer program for us to be able to effectively track them which will make our cohort a little bit smaller but it's something that we're looking to do as we move forward. In addition we want to look at the ACO impacts on the all payer model quality and population health outcomes so we do ask the ACO each year in their budget to talk about any initiatives that they're working on within their communities that might help address some of the larger population health outcomes that are part of the all payer model and we want to really try to do a deeper dive there so as I said sort of following that assessing the trend over time you know where possible looking at the potential impact of the ACO in some of those communities perhaps and seeing if some of those health outcomes are changing. In addition we're looking at conducting an analysis of ACO provider performance over time so I think Alicia had sort of pointed to this in her earlier presentation but looking at how providers perform within the ACO compared to providers who are not part of the ACO or were not ever part of the ACO and seeing sort of the differences or similarities there which is to heads up that those are things that we're hoping to look at and I really hope to be able to bring you into 2021 at least an update on where we are with some of that and as a note I think this is like one of everybody's favorite clients upcoming reporting for the all payer model and the purposes of meeting our requirements in the agreement so this is our updated timeline for 2020 italicized reports here have been completed. This graphic utilizes agreement deadlines and I just want to emphasize that some of these could change based on data availability you know our federal partners have been very amenable to those changes especially in light of COVID and so we do try to give everyone all signatories as much as as possible once we are warned of sort of that possibility so for right now let's dive into the reports that are upcoming so with that we have the pair differential reports that's going to be delivered as a package it will be the annual pair differential report which is section 10a of the agreement pair differential assessment report section 10b the pair differential options report and the annual assessment option service and so we'll be preparing that and submitting it as a package for December 34 submission we currently have a draft and are working with our state partners on that and look forward to bringing that forward to the board early in 2021. Annual state health health outcomes and quality of care as I said will be delivered as soon as data allow again last year it was in February and again run out is required specifically for the calculation of those HEDIS measures and the plan to integrate mental health substance use and home and community-based services within the financial target services that is a report that is designated to our agency partners and at this point the agency is proposing to delay that report so that it better aligns with some of the future APM planning that they've been working on and that does really kind of make great sense and we are in support of that so that will be up to them to put forth the request to our federal partners and I will keep you all posted as to the status of that as well once we receive word that that request has gone through and that's it that's all we have for you today I know this was a very short and sweet update and not as robust as we would typically hope but 2020 is not as anyone hoped either so I just any questions for Lindsay or I to walk through what we know so far about 2019 questions for Lindsay yeah I had a question for Lindsay on I think it's page eight just looking at the compound annual growth rates are those derived from the prior two years I was having hard time because a few of them like Medicare the first year of the 4.9 on the compounded growth rate is higher than the 4.4 or the 1.5 I understand the 1.5 you know the year two may go higher but just not sure how we could get a 4.9 and a 5.6 range just want to talk about that and then same with Medicaid which maybe there's a third year in there but the 2.9 is below the 6.5 and 3.8 so just because it's so critical obviously what the total compounded rate is going to be I just want to make sure the calculations were correct yep yeah so what I did and I will definitely go back and check my math but I took the 2017 rate which is not shown explicitly on this table I think at one point I did have every year's rate and the growth and the compounded annual growth but it was a really busy table so the 2017 rate is the denominator basically of that equation and then the so for the range I used the ranges that you see in column three the 2019 estimated range basically for each calculation I used the lower bound and got one rate and then I used the upper bound and got the other rate and that's how I came up with an estimated compounded annual growth range once we get those additional three months of run out and I could send I can definitely double check the calculations and I can send them to you. Sure yeah that would be good can you just send them that. Okay thanks. Well we're on that slide Lindsey I was trying to figure out how the range for all payer could be 500 to 558 when you're already at 544 and is that because you don't have confidence in the percentage of the three different groups or how would it end up being lower. I can I'll definitely double check the calculation but the the total that total range is a function of the so it's the total cost and then it's the all the members so depending on what I did was we used other years additional three months of run out to see how much that really impacted by payer and the additional three months of run out does not impact payers equally and so I can share those calculations but Sarah Lindberg and I worked on those and so I think basically some payers they don't we don't expect as much growth so that kind of drags down that average even though the PMPM remains the same it's unlikely that it will go down but sorry because it looks like it maybe should be 550 to 558 because as all of the range has increased from the first column so the 882 went to the bottoms 891 the 503 508 283 286 they all went up by about five bucks so it seems like the 544 maybe should be 550 but you guys can check on it and then yep we'll double check did you have other questions Maureen no I'm good thanks okay other questions from the board hearing none I'm going to open it up for public comment is there any member of the public who wishes to comment hearing none and seeing no hands raised I want to thank Michelle and Lindsey for providing us with that update and at this point we will move on to is there any old business to come before the board hearing none is there any new business to come before the board hearing none is there a motion to adjourn so moved second it's been moved and seconded to adjourn all those in favor signify by saying aye aye those opposed signify by saying nay thank you everyone and have a great rest of the day