 All right. Thank you everyone. You're still sworn. I hope you all had a nice little lunch break. I understand you're transitioning data and analytics arm to UVM. What UVM entity is receiving that data? This is Sarah Berry. We have a contract with the University of Vermont Health Network. The specific entity underneath managing the data is called the Data Management Office. How did UVM win the bid to take that work from one care? There was a strategic planning process initiated by our board that Vicky Loneriz described earlier in the day. From that, there was a strategy to look for efficiencies and cost savings as well as to advance our analytics overall. Through that process, the UVM Health Network was also looking to build out its performance under value-based care contracts. We saw an opportunity to look at joining them in the process that they were running to look at different vendors. It was really through that process. Was there a bid process? They had an RFP process. They would have to speak to it directly in more detail. One care staff participated in seeing different vendor solutions in setting specifications about what we would need to meet our current expectations of our network, and then it moved forward from there. You said they had an RFP process. Who's they? The UVM Health Network. But it's the data that one care possesses and is responsible for. Did you have an RFP process to select from potential vendors? No, there's two things happening at the same time. Back when this was all occurring. Coming out of the strategic planning process, one care found a need to look for alternatives. UVM Health Network independently was going to have its own process. We saw opportunities for synergy in that and explored whether the needs that we had as a network overlapped or aligned with their needs. From that, those criteria were provided out to selected vendors and there was an RFP process. We then were able to watch demonstrations and to indicate where we thought that the solution, the vendor could best meet the needs for one care's network. The vendor being UVM? No, the vendor being a company called Arcadia. How many entities did one care consider in providing this data to? One care considered all of the entities that the UVM Health Network was looking at for a vendor, but the vendor. Let me interrupt. Hang on. I'm getting at, did you consider anyone other than UVM? Did you? One care, when you're giving out your data, consider anyone other than UVM? No, we did not. We did not see a need. Why not? Because there were two strategies involved here. Ultimately, there's a new data platform that is a vendor. There is also the question that you asked me a moment ago about where which entity under the UVM Health Network, that is the data management office, will be managing the data. Those two things came together for us in an overall strategy to meet the requirements of our board. How could you evaluate whether or not UVM should take for monitor's personal health information as opposed to anyone else if you didn't consider other options? I think there's some confusion. It's not UVM. It is Arcadia that is the vendor. I understand the vendor, but you're doing this work with UVM, right? UVM Health Network is our sole parent organization. As part of our strategic planning process, our board directed us to look for options to advance our analytics that would not be duplicative and would not be more expensive than current offerings. Yeah. All right. Us doing this alone would cost Vermonters more money, and we would have dueling data analytics with our largest healthcare provider and our sole member organization. That's not cost-effective. You have about 300,000 attributed lives. Is that right? Correct. Just a little less. That's correct. Prior to this transition, did UVM Health Network have the PHI of those 300,000 people, or were there some they did and some they didn't? UVM Health Network or UVM MC has a existing arrangement with OneCare Vermont that's been there since our inception where they provide supports and services as Vicki described earlier in terms of employment point, etc. Through that, we've always received IT support and had appropriate protections in place. This effort that we're moving forward with advances that work because OneCare currently has a separate data vendor for a data platform. That platform will now be aligned through this agreement with the Health Network. OneCare still owns the data and is still responsible for the data as the Accountable Care Organization. We still have all the business associate agreements in place with all of the payers. If there is ever any breaches of data, ineffective use of the data, OneCare is ultimately responsible for that use. Thereby, we need to hold agreements with UVM Health Network to make sure that data is adequately protected. UVM didn't have all of this data before this change. Is that right? Sarah, I'm going to put that over to you. We use servers through the UVM Medical Center slash Health Network. That does not mean that they have the type of access that would be envisioned in this new arrangement as staff are moving over in that direction. Previously, this data OneCare used UVM services to house the data, but there's limitations and now those limitations are altered through this arrangement. Is that fair? That is correct. Is UVM operating as a covered entity or a BA in this arrangement? I can check and get you that answer. I can't answer it off the top of my head. Did OneCare provide notice and receive authorization from the 300,000 Vermonters whose PHI was provided to UVM? We annually have to do data opt-in and opt-out processes on new members, so that's part of the ACO requirements. There's not a requirement for us to, once we transition vendors, to get reauthorization for that as long as we have all the appropriate safeguards in place. There's a safeguards rule, a privacy rule, and I'm trying to understand at what was the mechanism through which this information could be shared with UVM. Under the privacy rule, you have opt-in authorizations being provided. People say you can share this information with UVM for these purposes, and then there are certain permitted uses. What I'm trying to understand is what was the legal authority to provide you, OneCare, the right to give this information to UVM. Chair Foster, my understanding is that everything that we're doing is under the allowance for payment and operations under HIPAA. In this case, what we're talking about is UVM Health Network acting as a subcontractor of vendor of OneCare for the purpose of those payment and operations. Great. Thank you very much, Miss Barry. That's helpful. What did OneCare do to ensure that that permitted use, the healthcare operations use, is the only use by which UVM has access to? Thank you for that question. That's why this process has taken us quite a number of months to put the contractual obligations in place. We hired additional outside legal counsel to advise the process and ultimately have very recently entered into contractual arrangements. There is some remaining work to be done before any data are shared under the new arrangement, and that involves ensuring that the final policies and procedures that dictate at the granular level, the detail around how data are handled, are well spelled out, and we have a written process in that contract to make sure that OneCare's compliance and legal officers review and approve those procedures before we move forward and actually share any data. If you can, we'd certainly like to see those, and we'd also like to see the diligence that was done on UVM's security prior to entering this contract or agreeing to enter the contract. One of the questions I have is, what role or impact, if any, did UVM's 2020 cybersecurity breach have on your decision to give UVM access to all this information? Starting with the beginning, we can certainly provide you with the additional information. I would say that there was not a direct impact from my lens of the cybersecurity tech and their response on the process that we went through. We did, at the time that that occurred, provide all of the required notices. We did the extra evaluative work that was required, reported to our payers to ensure that there really, ultimately, was not any detriment to any of the information that they held on behalf of OneCare. Sorry, so are you saying OneCare's data was previously exposed in UVM's prior breach? No, in the end, it was not exposed. Got it, but it could have been, but it wasn't, is that right? Correct. And then my question was what role, how did you evaluate their response and hopefully enhance privacy protections and determining to give them more access to this information? Can you ask the question again, please? So UVM had a very large breach which caused a lot of issues and certainly when entities go through this, you hope that they take significant remedial steps to prevent it from happening again. And I wanna know what OneCare's evaluation was of that in determining to give them this information. So we could certainly work with our internal team to get you some more information. What I can speak to directly is that not long after that time, we did some pretty extensive auditing work with them regarding the certification levels and the protections of data. Ultimately, they were found to be very well protected and as in any situation, there are obviously opportunities to continue to refine and enhance some of their procedures and they put a work plan in place associated with that. So we did not have any findings that suggested that there were concerns that would lead to hesitation as we moved forward. And you diligence that prior to giving them this information in connection with shifting your analytics to them? That process that I'm referring to was complete before we moved forward with this. And just to be clear, we have yet to give them any new information under this arrangement. And you all are UVMMC employees? Yes, our employment attachment is UVMMC. Do they set your salaries? Yes, we use the UVMMC compensation policy, but the board for me ultimately sets the CEO salary using the information gleaned from national standards. I wanna be respectful of my fellow board members' time in the healthcare advocate and the public. Just I think two little areas. Real quick, the benchmarking report, is that a final report that we received? The vendor has listed it as a preliminary report, but agreed to allow it to be shared with the Green Mountain Care Board. Do you think it's accurate and can be relied upon for you to make decisions as to your practices and for the care board to make its decisions with regard to your budget? To the best of our knowledge, it's accurate at this time. I think the reservation is that it is brand new information and we at OneCare continue to need to spend time looking at it and asking follow-up questions. In terms of the payment reform, shared risk, it's set at I think $36 million in the 23 budget. How did you come up with that amount and why is that the right amount to incentivize the behaviors that you're trying to incentivize? I can take that one. So generally the way that the risk and reward amounts are determined is through what's called a risk corridor, which is a percentage above and below the benchmark set by payers. And those can be anything you want. It could be a 1% corridor, it could be a 15% corridor. I would say that standard ACO arrangements tend to revolve around the 5% range. There's certainly ACOs that take on much greater corridors limits of up to 15%. We have largely, we negotiate those amounts with payers in order to find a balance between what type of risk we're willing to take on as a provider network and what type of risk or amount of risk the payer thinks will generate the right attention under these programs. And again, through the pandemic, reduce that amount and the amounts that we have in the budget that ultimately determine this $36 million figure represent increases up closer to what we had prior to the pandemic, but in some cases a little bit lower and the slight reductions relative to the pre-pandemic years really reflect the fragility of Vermont's healthcare system. It's an important- Let me plug you there just so I can, I gotta focus because I think I asked the question poorly. Why is it $36 million and not $100 million? We negotiate the terms with the total cost of care as set by the payer might be $500 million and then there's a risk corridor applied to that and that determines the dollar figure, the maximum loss or the maximum savings that providers can receive. So would a greater number provide a more significant incentive to achieve your goals of aligning conduct with curbing costs? It would, but it would also present a concern in the sense that some providers might say the amount of risk I carry is too great for my organization and they might opt to not participate. So there's a balance to be struck. And how do you see the, I guess the word is fragility these days of the hospital's finances impacting the temperature in terms of taking on risk? Very significant challenge. When we started with these programs at the beginning of the all payer model the landscape was quite different. From a financial perspective, the pandemic has caused a lot of challenges. You guys heard it all through the hospital budget process. So, like I said, I'm gonna go back to the word balance and say that we want to resume more material risk sharing terms because it does get attention and it needs to be done very thoughtfully with a careful eye towards the financial health of our system. What if hospitals or providers have control over the outcomes, which I think is the intent and they could achieve and make more money through this wouldn't that be a good thing for them to do given the financial challenges they're facing, right? Like if you give me an opportunity to make more money and I need money, I think I want it so long as I have an ability to impact it. Why is that not what's happening? I agree with you, but the factor that I think is important underneath it is what's the stability, the underlying stability of the organizations and even as individuals, we might place a bet on something but I wouldn't recommend placing a bet on a very fragile foundation. Thank you, that's a fair point. If there are losses, let's say they owe back $5 million as opposed to the $5 million they saved. Where would that money come from? Who would pay that? It's a hospitals, right? Larger the hospitals, correct. And how would the hospitals fund that? Would that be through Medicaid, Medicare, co-pays, all the various revenue streams they have? Basically, we'll come off of their balance sheets, essentially. So would any executives or individuals who are responsible for that loss have actually any skin in the game? That's a good question. We really put the organizations rather than the individuals at risk in this and one of the challenges to bringing this provider network together is getting the governance structure for each of these hospitals to agree to the terms. So I think the, without speaking for them, I think executives would feel some responsibility to their boards in the sense that if they had to make a large share loss payment, their boards are gonna consider that one evaluating management. Would that number, if there was a loss, come back through in our budget process here at the board? It would actually through the hospital budgets unless though through one care because we have a fully delegated or pass through shared savings and loss model. So essentially you could see a circumstance in which a hospital comes and said, boy, we had a rough year in these ACO programs and had to pay a $5 million shared loss payment. And so if the hospitals ultimately as an organization would foot the bill, is it fair to say that by and large Vermonters are paying that? Given that's the source of the revenue stream other than the Fed share, of course, which we're part of. I think through extension, there's some truth to that, but I will also add that the complexity of healthcare funding is huge. And if the general belief is that every dollar that funds healthcare comes from individual people, which is probably fair, then I'd say the answer is yes. So how would that actually change provider behavior or hospital executive behavior if they're not on the hook for any of it? Every provider is really trying their best to sustain operations for their community, especially these hospitals, at least in my experience. And there's a balance to be struck between the activities that generate revenue under fee for service and doing the right thing for individual patients. And what we're trying to do here is align these two factors so that when providers do the right thing for the patients, they're also rewarded financially. That's what makes this successful. Thank you for that answer. Look like the commercial insurers are not doing fixed perspective payments. Why is that? I think there was a thing that said low marketability, technical limitations, risk tolerance. I think it's slide 19. Is that why the commercial insurers are not participating in that? I want to speak on behalf of the commercial insurers and we may want to get into an executive session to discuss this in more depth as we are in active negotiations with them. I think it's about shared alignment largely in terms of what we're trying to achieve through OneCare Vermont and what their goals are. But I'll leave it there so I don't step into some territory in public. Well, is there anything that's not confidential that you can share as to why you think from your perspective, the commercial insurers are not participating in this? Again, I don't want to speak on behalf of the commercial insurers. So I'll just leave it at the answer. I'm asking for your perspective, not speaking for them, your perspective. My perspective, I think it's the alignment issue that I mentioned before. We're trying to install true fix payments for providers that establish, here's how much you should get paid for the work to care for this population. And I think some of the challenges that naturally come up are how do savings that the providers generate get back to the ratepayers, for example. That comes up as an interesting dynamic and I think it's a valid point but one that represents this kind of a misalignment between what we're trying to achieve with the provider system, how the system is funded and paid for versus what the commercial insurers see as their value proposition with their members. Okay, thank you. The CEO compensation is projected to be $491,000 in fiscal year 23. And I understood from the responses to the staff that that includes bonus. Does it also include retirement benefits, any sort of severance package or any other financial benefits? And then corollary, are there any other financial components to the comp that are not included here? The table that we supplied was designed to be, it's a projection but designed to be like what an individual's taxable income would be along the lines of what is reported on a 990. It's a little difficult to project that frankly but that was the intent when we supplied that table. Thank you. To the CEO, do you think you're adequately compensated? Yes, UVMMC goes through a very rigorous process to benchmark the CEO salary against other CEOs and like organizations and the board reviews that and makes a determination on my annual salary. And do you think if you were compensated more generously, you would be greater incentivized to achieve outcomes for a monitor or to not make a difference? I think I'd like you to restate the question. Do you think additional compensation to you would provide an additional incentive for you to reform one care's mission on behalf of Vermonters? No, from a personal one. I'm just gonna speak on a personal basis because every CEO is different. I think that you need to be reimbursed based on fair market value and that individuals will make decisions based on what they hold important to them. And for me, it's the mission of one care Vermont that brought me to one care from the state and that's how I continue to be passionate about that work. What was your salary, your first year as CEO? I do not recall. Well, I could get that for you, but... What year did you become the CEO? I've been the CEO for about three years now. So I think it was in 2019, August of 2019. The 990 from 2020 indicates the salary was 377,000 and now it's projected to be 491. What are the performance metrics that went into determining that increase? So remember in certain years, and we can get you those details. All the executives took a pay reduction due to the pandemic and forfeited any of their variable pay as a part of that. So those factors would have to be taken into consideration. So the 202990 at 377 you're saying is depressed because there were variable comp not received? Correct. In terms of the 491 projected compensation, how much of that is tied to incentive-based compensation? I actually just received an email from the staff team and we'll supply a breakdown accordingly with the base versus incentive opportunity. Could you provide to me now? I need to have somebody on my team pull those data. I can try and get it during this meeting, but it'll take a little bit of work to break it apart. What about last year? What percentage, Aine, give me ballpark, was the compensation for the CEO incentive-based? Vicki, you recall, I can try and let me try and look it up. Hang on. I don't recall. So it all follows UVM MC's policy of variable compensation, which the Green Mountain Care Board does have copies of. So at maximum, the CEO can obtain 25% of their base pay through variable compensation and VP's have a different rate and then directors have a different rate as well. That's that year over year. And that is assuming they pay out a variable compensation, which they do not in every year, and it's determined on whether or not we meet our corporate goals. And that's what I'm trying to understand is how the comp is tied to the corporate goals and what the metrics are that are being evaluated and determining what the comp should be. You do have a copy of our corporate goals year over year, so you would be able to look at those to see exactly what those corporate goals were. What I'm getting at is like, I want to see how that translates in the evaluation to determine the CEO level compensation. Like I get what the corporate goals are, but are those actually scored? How are those evaluated in connection with determining compensation? Those are scored initially by our executive committee. Our executive committee of the board of managers makes a recommendation to the full board and the full board ultimately decides on whether or not there is a payout. If so, what is that percentage of that payout? And that's done on an annual basis. Do we have that? Do you know? I don't know that you have individual employee evaluations I would not think you'd have that information. And from your perspective, does the executive, the CEO and the other executives compensation comply with rule 5.203A? You'd have to tell me what that rule is. I don't have it in front of me. I can generally say what I think it is. I don't know how to have the language, but it's that the ACO structures executive comp to achieve specific and measurable goals supporting the ACO's efforts to reduce costs and improve quality of care. Yes. Your comp is tied to those factors. Great. And would you serve as one care CEO if you receive less compensation? I'm making more coffee just so you know. Oh, it's burning. Sorry. I think there's another mic on my question. Would you continue to serve as one care CEO if you receive lower compensation? I think it would be dependent on what that compensation was and whether or not it was within fair market value for my services. All right. Thank you all for answering my questions. I appreciate very much. And with that, I'll turn it over to Jessica Holmes. Thank you. Okay. Thank you. So first of all, thank you for the efforts that you've gone into preparing the submission. Appreciate that. I have some questions. Some questions have already been asked by other staff or chair foster, but I will go through the questions that I have remaining. And some of your comments actually created new questions for me. So one was my first question was around the how many, basically, so you have 500, 5,128 providers. How many of those deliver primary care about just roughly trying to get a sense of how many of your providers in your network are primary care providers. We have 54 tax ID numbers. We'd have to do the math for you on how many providers. Because remember, UVM medical center is one tax ID number. They have hundreds of primary care providers. Okay. I mean, I guess part of my question revolves around, you know, you had 78 respondents in your primary care engagement survey. So I'm trying to get a sense of whether you've assessed whether those providers are representative of all the primary care providers in your network. 78 seemed below to me, particularly now that you said there's hundreds within UVM alone. So have you done an assessment to see whether they are representative of your primary care network? We've not done that assessment, but we don't dispute kind of the concern that you have about the number 78 being low. It's actually quite a grave concern for us as well. And one of the key learnings that our staff are reflecting on right now to try to think about how to do better is, is there a better or different mechanism to get the survey out to encourage engagement? So we tried to use kind of a networked approach where it went out to key people at the sites and then from them to the providers within their organization. And what we learned is that did not work very well, despite multiple reminders and outreach. So part of what we need to do is A, be careful that we don't overstate the value of those preliminary pilot survey results, but yet we use them because I think there are some interesting signals that we start to see. And second, that we figure out how we change our strategy to better engage and get higher response rates for primary care, but also as we think about the other segments of our network that we want to survey. Yeah. And did this survey instrument include questions that gather specific examples of how one care's investments, data analytics and payment incentives have fundamentally shifted how those providers actually deliver care? Like is it, is there evidence in that survey being collected about meaningful and measurable delivery system transformation that's directly linked to one care specific efforts? So if I, if I'm understanding your question correctly, that it's really assessing like is the survey assessing change in behavior and outcomes, the answer would be no. The survey was designed to actually look at people's understanding of healthcare reform, the ease of use or the difficulty of use of some of one care's systems and tools, their knowledge and understanding. So it was, it was framed quite differently than what you're suggesting. Well, then let me put in a pitch for the, as you roll out the next version of the survey and hopefully have a greater response rate. I think it would be really helpful. I think a lot of the questions that we've asked over the years around evaluation are trying to understand, you know, how do one care Vermont specific policies, programs, investments change the delivery system and change outcomes for patients. And so asking specifically, you've got a provider survey out in the field. That's a good way to assess how things that one care is doing are actually changing the delivery system. So I will put in a pitch for that. Hopefully that you'll consider. Happy to see that you're hiring an evaluator. Again, you know, this is something I've been pushing for years trying to get more evaluation. Something that's weighed on me for the past year is that we've been celebrating, you know, our relatively low total cost of care for Medicare. And perhaps we should, but I want to ask you about our wait times. So our wait times are excessive in Vermont, particularly for specialty care, which is disproportionately used by seniors. So how does, for example, the Medicare benchmarking report or one care Vermont assess the role that wait times and access challenges might play in one care's Medicare cost performance. I'll let Dr. Wolfman address some of this, but just to start in terms of the Medicare benchmarking report. I think one of the early things that we are very interested in and concerned about is that in those reports, our ED utilization is particularly high. And we have concerns that that is a signal that it is high, perhaps because of access or wait time issues. So that's one of the things we're looking at. We are digging in more deeply, as I mentioned earlier, specifically to the transitions of care issues. And I know that the board is well aware of these as well. They're in the news, but really understanding how patients not being able to leave the hospital to get to, say, a skilled nursing facility or back to home with appropriate supports is definitely having an impact on their quality of care, their desire for the place and services that they want to receive. So I think what we're trying to do through this new lever is shine a different light on that and use the national benchmarking approach to really indicate that there are some, there's some need, some very specific need to look at certain parts of the system and try to address that. Now, I think it's premature to answer the question, what are we as an ACO going to do about it? Because as I mentioned, we haven't even disseminated all of this information yet, but it's critical ultimately to the health of the healthcare system. I agree with what Sarah said. And I'll just add, I think we have a wait time problem for all areas of healthcare. It's not just specialty care. It's getting out of the hospital to go to SNF or rehab. It's for primary care. It's for, you name it, ER wait times are horrible. We know. So it's everywhere we look. And I think we cannot underestimate the impact of staffing issues that are huge in all those areas. I definitely think that we have the need to educate the patients more about where to go for their care. And I don't want us to underplay the responsibility of the patients in helping with, you know, solving these problems. So if a patient of mine thinks they have a mole that needs checking and they don't get to see me on the day they want at the time they want, they might go to the ER. That has happened. So, and many other examples I can give you. So I think we're working on this together with our providers in all kinds of different ways, but remains a heavy burden. Well, let me ask you a follow up question about the budget then and thinking about, you know, where in the budget are, would we find resources allocated to address some of these opportunities that have been identified in the Medicare benchmarking report for improvement, you know, specifically, you know, the lower than expected primary care usage, the higher than expected ED utilization that you mentioned. So where in the budget are we, will we see resources specifically allocated? I know you may not have steps, action steps identified, but are there resources already allocated to address opportunities for improvement? I think there's two parts to the answer to that question. The first is we just received the data and the budget was developed months prior. So, you know, there's a cycle that we have to go through to make some of those broader adjustments. Having said that, kind of knowing the broader landscape, I think you could look specifically to the enhanced support for the CPR program and the flexibilities that that provides for allocating funds within those sites for staffing and to meet some of those needs. And the second is a line item for specialty care, which we're still working on some of the details, but Dr. Wolfman is leading some efforts with the state and with others around some of the problems in skilled nursing facilities right now. And so you'll hear more from us as that emerges over the next couple of months, but those would be two examples. And just as a follow-up, then I recognize the budget was produced before this benchmarking report came out. Is there any appetite for shifting some of those resources now that you know a little bit more about the benchmarking report? Would you, if you could submit your budget now, would it be the same budget? I think our budget is built and approved by our board based on the amount of revenues that we have coming in from the hospitals and the payers. I don't think there's an appetite from the payers to give us more money for these services, but you could certainly ask them to. No, I wasn't thinking that you would have to add more, but you might shift resources within the same dollar amount, right? So you might just shift programmatically allocation of resources given the data that you're saving from the Medicare benchmarking report. I think the only challenge would be is that providers like primary care sign up based on the population health payment programs that we're supporting. And if you change that, you've changed the contractual agreement that we've made with those providers who have signed on. So you could suffer a loss if you did that in your provider participants. Okay. Could I add a couple of clinical comments? We are also through our population health model incentivizing some of this work. So the two care coordination outcome measures that we have built into the population health model for 23 are follow up after two avoidable, potentially avoidable ED visits. So getting people in, if they've had two ED visits in the last 90 days, incentivize people to get them in within the next 60 days so that they don't have a third one. And working together on that across the care continuum. And then also hypertension follow up is a process improvement that we are requesting as our care coordination, one of our two metrics for the population health model. So if somebody has a diagnosis of hypertension going forward, we're not just saying, oh yeah, this year we're going to get them in within a certain timeframe in order to get credit. So that they have adequate follow up. So I think those are very important metrics that we are adopting for 23 and we will measure that. They will, you know, we will measure the outcome of those two incentives. Okay. My next area, you cite a few challenges to success. And I just wanted to probe a few that you mentioned. One was you cite as one challenge the expansion of enrollment in Medicare Advantage plans and highlight that this needs to be addressed in future visioning. I think those are exactly the words that were used in the submission. So I'm wondering what is the path forward to achieve meaningful scale and specifically what role does the new collaboration between UVM Health Network and MVP play in the ACO's scale success and future visioning. I can speak to that. So as we discussed earlier with our initial strategic planning process, you know, started in 2021. The plan was at the time to roll that process through 2024 because we thought at that time there would be only a one year extension to the all payer model agreement and instead we've gotten a two year extension. We have been highly focused this last year trying to understand if there will be any adjustments made in the current model, which we're being told are not. And so next year as part of our strategic planning process, we're going to have to understand what are other options that are available to us as an ACO that we can enter into directly with CMS, CMI, the state, perhaps certain payer partners, if another all payer model agreement is not beneficial to our provider network. So that needs to be the process from which we build on and our strategic planning kind of refresh next year to look at what are those paths that would be viable to us as an ACO in Vermont. So that will be taken up as part of that strategic planning process. Okay. With respect to the challenge that you cite about the absence of Medicare and commercial unreconciled fixed payments, I'll leave the Medicare aside for now and focus only on the commercial. And I know chair Foster asked you this question and I recognize that some of it may have to be relegated for an executive session if we go in there, but perhaps I can ask it slightly differently that doesn't reveal confidence as you reference these three barriers. Technological limitations, low marketable value and low risk tolerance from fee for service as the commercial barriers. So I'm wondering how you were able to successfully overcome those barriers in the CPR program and in the SVMC hospital pilot program and why those strategies can't be scaled up. Well, I'm not sure that we have solved it. We have a, I'll call it to kind of a bandaid approach to make CPR work because it's been a priority area of ours. And by that I mean at the end of the year we do have reconciliations between one care and the payers that require a reconciled payment. We just don't charge it to the CPR practices. It gets put into the hospital settlement. That is not my ideal scenario for this and it is a barrier to making this a bigger and broader program. And so in short, I think we've made it work, but not in the ideal state. And the SVMC program similarly. Yeah, I'd say it's similar and credit to SVMC is that they offered to be a pilot site to help us test this out as a new initiative and they've largely stuck with it. I think partially in hope that it would move to a truly unreconciled model. If we could, I don't know if you have your submission in front of you, but I wanted to talk to you about tables 6.1 to 6.3, the variance analysis. And this is looking at the revised fiscal year 22 to fiscal year 23 variation. And you list a 26% increase in revenues coming from the Blue Cross Blue Shield QHP program. And in the table, the tremendous growth and revenue is attributed to approved QHP filings. So can you help me understand how that, where that 26% growth rate comes from premiums didn't rise by 26% and according to slide 14 attribution to the Blue Cross Blue Shield QHP program is predicted to fall. So I'm really just trying to understand that growth rate. I can probably answer that better if I have a little bit more time with the numbers, but my initial thinking is that it's against what the numbers reference. So what is the 26% reference against if it was last year's budget, then that could be 26%. In other words, if last year's budget was lower than we anticipated or relative to what we're experiencing in the market now, it could look like there's a bigger increase. So the way in which that the target was set was we looked at emerging 2022 spend data and built on top of that, if memory serves me a 6% increase, which is identified as the medical expense component of the insurance rate trend. So that was pretty clean and straightforward, but if the 26% is referenced against a prior year budget, there could be another variable to consider there. Well, maybe if you could follow up, that would be helpful. In the variance table, it's the revised budget. So it's not the original budget, but it's the revised budget. So presumably you would have more up to date than the original 22 budget. So it would be helpful to us to understand. Rather large. It's a pretty significant amount of money as well. Not only percentage wise, but also just dollars. Also, you're you're budgeted $1.87 million for software, and I'm wondering if you can just give us some more details on that. I know you're your sunsetting care navigator data analytics are being outsourced to UVM Health Network now under contracted services. So what remains in that bucket of $1.8 million for software? Good question. So this is a transition period where one care largely has to maintain its ability to deliver for analytic support to its net worth while the Arcadia system is being built up. So there are some software tools, including the current data warehouse tool that we still are paying for through this transition period. What we expect to see in future years is that we can start to sunset some of these software expenses as the new platform is up and running and ready to deliver supports to the one care network. So in a follow up, would you be willing to supply a breakdown of that software and then what you anticipate will be sunsetted, you know, in future years so we can understand what the ongoing software costs will be and what you're you know, maintaining in duplication this year. I think we could supply something like that as long as always careful about disclosing software or vendor pricing information. But if we can do it in a kind of a generalized way, I'm happy to do that. That would be terrific. You can work with our legal team in terms of what's confidential and what would be allowable. My other question in terms of the budget is around salaries, less purchased and contracted services. I'm adding the two together because I recognize there's been movement, particularly this year between the two with the new UVM Health Network data contract. So I'm going to call this a human capital bucket if you will. And that's hovered around nine to ten million dollars since 2018. When I look at that bucket between 22 and 23, I see about a 12% jump. And I'm trying to figure that out because the number of employees is lower. Salaries are only rising by 3% on a smaller number of employees. And the UVM Health Network contract is supposed to be at neutral. So I'm trying to figure out where the 12%, you know, you go from in 2022, I think I have 10.7 million dollars collectively in that bucket. And then in 2023, it's about 12 million dollars. So can you help me understand that combined growth in what I'm deeming the human capital bucket? One moving part to mention is as part of the transition to the UVM Health Network model, the vital contract is now in that purchase services arrangement. So that's kind of a non-human capital component. The other that I'll mention that has grown over time is legal expense. That's been a pretty significant growth area for us over time. And more closely it's also where our actuarial expenses live, which has been a growing expense as well. And audit. Audit has grown from an expense base also. I think probably what will be really helpful is for us to understand some of that. There's a way to deeper dive into that because it's not clear from what you submitted where all those changes in those dollars. So I think particularly if you go from 22 to 23, it would be helpful for us to understand those moving parts with fewer employees, salaries of 33%. If you add up the contracted and purchased services, it's hard for us to offset what is UVM and what is some of the other buckets of services that you're providing. So if you could just help us do that walk through, I think that would be helpful. Sure thing. Thank you. My last actual question is around because I'm also trying to be cognizant of as many other people that have to go after me. We submitted some data in appendix 7.4 that illustrates the proportion of patients in the high-risk groups whose care is managed and coordinated. And to be honest, I was surprised by the proportion of high-risk patients whose care is actually being managed is quite low. Only 5% of patients in the very, very high-risk level report being reportedly being managed and it's only 6% of high-cost members. So I'm wondering if, and maybe this is a question for Dr. Wolfman, did those reported percentages surprise you, given all the efforts that OneCare is taken to manage the care of the folks in that fourth quadrant? And how do we interpret those numbers? And I recognize, I read all the footnotes there and we can't compare 21 to 22, although I would like to, but I recognize we can't because it's a different question mechanism, but given the data in 2022, those numbers seem surprisingly low to me for that high-risk category. I agree they are lower than we would like. I can't give you all the reasons why. We are always driving towards maximizing that. I can look into it further. It does differ across pairs and it differs from HSA to HSA. So there are a lot of factors that impact that, but obviously our goal is to keep moving up. There's a little bit to do also to switching from Care Navigator for record keeping to our new methods and that's settling out still. So we're still in transition and so the rates may actually be higher than what we were able to report. Do you have I guess I'm thinking, assuming your new population health management payment strategy and bonus incentive systems work, these numbers should rise next year. So could you submit, and if you don't have them today, understandable, but could you submit your target levels for what you're anticipating, the percentage of patients in each of those categories to be managed for next year so that we can get a sense of how well your track and progress towards those goals given that you're changing your payment mechanism to try and maximize care management. Absolutely. That'd be great. Thank you. I think I'm going to kick it back over to you, Chair Foster, given how much time we have. I think you're fine if you'd like a little more. If you're all set we can come back to if you'd like. Do you have more? All right, well, let me go ahead and I have a couple of questions, but I can see if others have those similar questions then I can come back. Thank you. I sort of budgeted 30 to 45 minutes per member and if people go over under, that's totally fine. So next we'll go to Dr. Merman. Hi. Dave Merman, new on the board. Nice to meet most of you for the first time, a few of you in the past and I have a lot of questions for you. I'll try to trim it down. They keep growing through each hour, so I guess I just want to start with like an introductory remark, which is to say thanks for your budget and presentation and all of this overview as you can understand I'm sure that coming to try to understand all of the intricacies in the last six weeks has been a bit of a lift for me as my preconceptions of what an ACO and OneCare is have been completely flipped and I hope that I understand this well. So I may have some redundancy in some of my questions of what things that you've covered elsewhere and I apologize for that. I just want to be clear that you guys understand that our perspective on this is from the care board is that we are tasked with, you know, we're regulatory agency that tasks with improving the health of the population of Vermonters, reducing the per capita growth and expenditures for health services in Vermont across all pairs, although I think we're, you know, particularly concerned about ones that affect Vermont commercial payers and Medicaid while ensuring access to care and quality is not compromised. Enhancing patient health care professional experience of care and recruiting and retaining and achieving administrative simplification. So each component of the health care delivery system shares many of these goals but are often not entirely aligned by different market forces, incentives and other priorities. So just understand that our questions and my questions today come from this perspective, which is in these aims, which is to drive improvements in access, affordability and quality in health care to improve the health of Vermonters. So with that sort of background, I guess the first question that I had in reading through all this and listening to all this is that clearly you are people that think a lot about health care, health care delivery, health of the patients, population of Vermont. And so my first question is, and I'd love to hear from any of you, is what you think as a state, as a society, what are the things that we can do from here to improve the health of Vermonters? Not necessarily one care or ACOs, but what are some of the things that we could do and I guess then if there's some things that one care can address, then that's I guess the ones that are most exciting to me. I can start at a very high level. What comes to mind for me is that I think we need to grow broader understanding of true population health and we need to be putting more resources and intentionality around preventive based activities and I think that you know the health care system in the United States is kind of perverse in that sense that we're really focused on treating acute care and illness and not enough upfront and that's one of the issues that I will say we at one care grapple with but it's an issue that we hear from providers across the state as we have conversation. Add to that a couple different perspectives as well or additional perspectives will say first is having a healthy care delivery system and I mean that broadly in that it's not just financial health of organizations but there's provider satisfaction and they are already willing and able to care for patients so that's something I think about a lot in these programs is you know under CPR the comprehensive payment reform program for example our providers actually more satisfied in this type of arrangement and therefore can deliver better health care their focus is more on the health care so I do think about how do we make the health care system itself high-functioning as it can be and then that should in my view lead to better health outcomes for patients. The other thing that's really in one care's wheelhouse but not exclusively is the use of data I think the data that we have sheds light on opportunities that are otherwise invisible in our system and we can really do a lot with these data in terms of identifying opportunities for specific interventions specific improvement areas so that we can collectively raise the bar and that you know every diabetic patient is well controlled now and we know exactly where we stand that can make measurable improvements over time. Yeah Tom I would just agree with what you said and add on in terms of workforce and having a happy and satisfied workforce and I think part of that that could be better reviewed or looked at and maybe something that the care board could take a look at is what are those administrative burdens that are being placed on health care providers right now and is there a way to be able to streamline and simplify some of those burdens because what you're trying to do is create a better mouse trap in value based care and you know you have to always have regulation and smart regulation is good regulation but you can't put additional administrative burden on your already fragile system unless you have a real reason for doing it and making sure that the reason you're doing it is that people are going to be better off at the end of the day and people that's like all vermonters like that's what we're trying to get at are people better off because of this new system approach or not. Yeah it's interesting all three of you kind of spoke to things that I haven't further in questions and so Vicki if I could start with you which is I'd actually cross this question out but you know what has one care describes that they do in the budget submission that there is a reduction in administrative burden and I was wondering if there's a one is there a way that one care measures that reduction in administrative burden or at least from a survey standpoint if we know reductions are occurring and if that could be quantified in some way as a decreased impact on those providers I mean we all know that primary care providers are burning out with pre-authorizations and complying with certain documentation and regulations but what is one care done and how do they quantify it to reduce administrative burden. Vicki we haven't surveyed right to get an exact percentage on how we've done this but I can tell you a few of the ways so through our contract with Medicaid the providers that are part of one care have administrative relief of prior authorizations for select services because they are agreeing to be accountable financially and clinically for certain measures so that provides a measure of relief for all Medicaid individuals that are in the program and their providers as part of that we have done things internally to be able to reduce administrative burden back to the providers as Carrie mentioned through our population health model we used to have care coordination metrics, value based incentive metrics population health metrics it was all in support of caring for the person and what better outcomes so why don't we blend those all together take a more holistic approach and get down to a few measures that are meaningful to providers that's easier that is not easy to do right because all payers have their requirements that they'd like to see and things we they'd like to measure you as a Green Mountain care board have things that you would like us to measure and so this is really trying to get at what are those measures that the clinicians believe are valuable to measure and patients are better off because of it so those are two concrete examples of things one care has done to be able to reduce the administrative burden on health care providers and the payment reform alone provides a lot of flexibility in terms of the way care is delivered to Vermonters and not having to be applied to certain CPT and ICD-9 codes in order to build for those services so more flexibility in the way that care is delivered is what I would say Sarah I want to just follow up on your thing with prevention I think one of the things that we struggle conceptually with I think you're a pediatrician or we're a pediatrician or are a pediatrician or once maybe worked with them for a long time because you know pediatric is really the place where prevention is occurring and for primary prevention and then we're sort of stuck with secondary prevention for the bulk of our years and then a lot of the metrics that we're using to evaluate the quality of health in Vermont are A1C scores, hypertension depression screening I don't know I guess from my perspective I feel like we're just sort of scratching the surface of what really health care value is when we're talking about those things and that prevention really is almost precedes the delivery of health care but with that in mind are you do you feel that these metrics that we're following like A1C less than 9 I couldn't figure it all out do you have any understanding whether or not this is I mean a lot of these are really long term things but in the short term do you have any data or signals maybe that this is reducing cost reducing disease reducing hospitalizations you're asking a wonderful million-bizillion-dollar question really and so I think there's multiple components to it I spent many years working with pediatricians and family practice physicians and from that process learned that really a multi-generational approach to thinking about and integrating medical need and social need is incredibly complex and quite necessary to be thinking about the primary prevention strategies and so one care has a couple of things that we're working on with respect to the quality measures you're absolutely right we look at chronic disease management and that's an important component to controlling costs and improving outcomes but we also look at proxies for preventive care so for children and for adults we look at the use of wellness visits age-appropriate wellness visits screenings developmental screening for kids being a good example depression screening for adolescents and older adults and that's just the start we also really try to think about where there's space for innovation so you'll see one care in its budget continues to invest in a program called Dulce which is a partnership between local pediatricians offices parent child centers and legal aid to really support new parents so parents of newborns and young children to identify some of those social stressors environmental needs and provide immediate referral and linkage to services to really try to get in front of and make a generational impact on some of those challenges that have existed so it's small and one of the challenges we've had frankly is how do you expand that model statewide when the birth rate is declining and we might not see in each practice enough newborns to actually make that model work continue to think about what are the strategies and what's the right place for those strategies is it in the patient center medical home is it in the community is it partnering in a different way I think one of the things that I'm struggling with when I'm trying to understand what the potential impact of an ACO is within preventative care is this charge of the care board which is trying to reduce the per capita growth rate of expenditures in health care seems that we can throw so much at prevention that the gains of that are 510 20 30 years out and we've got this sort of you know confluence of crises going on right now where hospitals budgets are really struggling insurance rates are going through the roof inflation staffing and whatnot so I guess the follow-up in that question I guess you know and when you all as one care as individuals think about cost drivers in health care you know and what those are are there cost drivers in health care that you think that one care I guess actually as one care can one care augment these things that are driving up the cost of health care and if so how well I think one care tries to shorten the shorter term as I guess I'm trying to say that's the difficult challenge right there is the timeline and so I think what we continue to struggle with and have conversations through all levels of our governance is how do you manage these one-year payer contract cycles and performance expectations with mid and long-term outcomes that our clinicians remind us all the time it's going to take years decades generations to address and so I don't know of a secret formula that says here's exactly how much we should be investing in specifically versus chronic disease management I think we're continuing to refine that but one of the most important messages that we as the staff at one care try to convey all the time to our provider network is that using the data not everything needs to go down like costs may need to go up in primary care we might need to actually incentivize more visits for people who are very fragile or have needs and that's okay and good to be offset with a broader vision of where are the avoidable you know areas of utilization and how do we address those all I guess where how do you address the avoidable areas of utilization and you know I think the big expensive utilizers are you know or the big expensive cost centers are going to be hospital based procedures admissions visits how does one care incentivize people to get care in other locations or in less expensive hospitals places to get procedures I think there's multiple strategies but as Dr. Wolfman spoke about a moment ago certainly our care coordination program is a large part of it and the work that we've done in the last couple of years to get more precise in sharing information not just about a large swath of individuals that might benefit from generalized care coordination but specifically looking at those who are showing back up at the emergency department does one care have like any specific programs to try to encourage hospitals I mean it's such a tricky time right now so like you know hospitals are so struggling the budgets are complicated the labor cost is through the roof I mean I think you know I work in the emergency department our volumes are super high the census of the hospitals super high the census of the SNFs is super high you know access is super low it's a really complicated time to work on you know boom I mean costs are just going up super very quickly in health care you know year over year are there programs that one care has to work specifically with hospitals to try to reduce costs within hospitals or push hospitals to encourage hospitals to move to say to outpatient surgery centers or other lower cost areas to deliver care do you want to speak I'll put a plug here for payment reform and that if we can change the way that these high high expense areas of the health care system are paid and one that's more of a capacity based model rather than a volume based model it does help to stabilize overall costs and the challenges it places on those facilities and organizations is to live within those means here's your Medicaid fixed payment for the year you need to run your organization in a way that lives within that budget amount and then on top of that you layer in the potential for shared savings or loss as another factor so what I hope happens to these programs that all of a sudden these the hospitals see alright my budget for Medicaid is paid and now if I do extra which is move to lower cost settings to do better work with prevention I can also earn some shared savings and then I think the system starts to work better is more focused on the health outcomes so Medicaid with fixed perspective payments has some of that now would you say that the fixed perspective payments going to hospitals would incentivize hospitals to be try to figure out how to be more cost effective while maintaining quality in their care yes I would agree and then what are the quality metrics then for hospitals within that that's a good question we're starting to discuss that with Diva around this Medicaid fixed payment expansion initiative but largely it's been the same quality measures that were accountable for broadly under these ACO arrangements but I expect there to be some more facility specific quality factors looked at in the future I think one question I'm kind of scattering around my questions here but I appreciate your guys comments but one question I had that I when I was reading through the budget submission which I think was kind of an anecdote regarding a potential cost savings in the Burlington HSA was how the I'm just going to read why I have an example of how one care is improving care and that is discussed in the Burlington HSA reductions in the increase in admission rate growth and that there's this observation that the Burlington HSA limited the increase in admissions from I think it was 21 to 2022 from like 7 Nish percent to 1 percent increase in growth and that was thought to be as listed as a quality improvement and I guess how can you observe that this decrease in admissions is a quality improvement due to one care I think ultimately we're very cautious about questions of causality because as I talked about earlier there are so many different interventions so many organizations that are involved in these things what we focus on is trying to provide the data the resources the information and when we see best practices that we try to serve as a vehicle to disseminate you know what is happening in the northeast kingdom that maybe the southwest of the state would want to know about or vice versa and more recently one of the mechanisms we've just started using to help facilitate that is by inviting some of our network to present at public discussions of our board meeting to really highlight some of those success stories and we'd like to see more of that happen I think this specific thing that concerned me was like is this increased quality or is this decreased access and are we seeing the impact of difficulties of getting inpatient beds in the Burlington HSA and that's why admissions are down I know that patients board often for a long time at hospital in the Burlington HSA and that they subsequently don't get admitted so sometimes they get nervous with some of these as you mentioned sort of causative sounding things that really are observational let me just flip to one other I wanted to bring up another issue that I think and I'll try to have my sort of drawn out case story is that emergency physicians seeing elderly patients who are near the end of their lives but basically it gets to the point that I think a lot of my patients really want struggle with having really intimate conversations with their providers and they're focused on diabetes management hypertension management when really like they're trying to figure out how to manage the later years in their lives which gets into the question of goals of care and often in the emergency department we'll see patients who don't really have well established goals of care that are critically ill and we spend we're happy to connect with these patients and it's really incredible work but it often feels like we're doing a lot of really expensive testing interventions unnecessary testing hospitalizations when it really kind of turns out over a period of time that really this is not consistent with what this person would want in their life and so I guess my question is is one care looking at trying to incentivize providers to have goals of care conversations palliative care type conversations end-of-life care conversations with patients in a way that that is universal I'd love to answer that Hi Dr. Merman I am a family doctor in Brandon where I've worked for 24 years and I still see patients and I couldn't agree with you more on that topic it isn't solving it quickly but we are convening a work group to work on that kind of topic I'm a big believer in planning for appropriate care in the primary care home and being willing to have those discussions in a timely fashion so if a patient doesn't really want to be in the ER and run up a huge bill with expensive testing then that doesn't happen or if they do let's talk about why so a special we're going to have a work group called living fully supported and it will include topics like that and palliative care and SNF challenges etc Thanks I think it's just incredibly important work I know you work as a family doc and I'm sure that's a daily patient interaction is trying to figure those things out I have a few more questions which is also is one care able to do anything to try to improve the complex issues relating to SNFs and rehab facility access staffing is there any levers in your guys wheelhouse that you can move to try to improve the ability to move patients from inpatient to longer term care I'm happy to answer that also okay we have been having discussions with the state and with the uvm health network medical group administrators and with a lot of different providers as well as the medical directors throughout the state who oversees SNFs about this problem and we are moving the needle forward slowly I have a meeting tomorrow again about this but one care has put aside some funds and is willing to help with a pilot and some initiatives in this area we haven't firmed up the whole plan yet but more to come and we are focused in on helping with this issue because I when I think of cost drivers in our system right now I guess I feel like the challenges of moving people out of the highest cost settings into lower cost settings who don't need that level of care is probably a pretty significant cost driver I don't agree so I have a few questions that came up while we were talking here today um I have one here I have a few prior questions so regarding the Medicaid total cost of care so I see it is on page 22 of the budget submission is 306 million dollars but only 171 million is unreconciled is that is that different suited the non attributed Medicaid patients or is there another reason why the rest of that is not unreconciled great question so the way that total cost of care is determined is we take the attributed population which is around 100,000 roughly for Medicaid and project the total cost of care for those patients and that is really the total cost of care it's healthcare expenditures regardless of where it's delivered whether locally down in Massachusetts and Florida the subset in the fixed payment presents just that portion of care at the providers accepting a fixed payment so just at the Vermont hospitals who are under the fixed payment arrangement for the other care it is paid by Medicaid on a fee for service basis that they build a claim Medicaid pays it but it's part of our accountability and ultimately determines whether or not shared savings are earned or shared losses are owed okay thank you that's super helpful so and then to pivot to the whole one care UVM relationship which I must admit is something that I don't think I quite understood before today so I guess first of all so is one care a subsidiary of UVM MC or UVM HN or is it a separate organization we are a separate LLC 501 C3 organization whose sole parent or sole member is UVM health network our members used to be UVM MC and Dartmouth Hitchcock health that changed about a year and a half ago to UVM health network being our sole member I would say the difference between what you might see with other UVM health network affiliates is that our board of managers is fully responsible in charge of our budget personnel strategy expenses and UVM health network does have members on that board do you Vicki have a reporting structure within the UVM health network other than the board not the board of one care I do not my reporting structure is up to the board of managers so only the board of managers can hire and fire the CEO or the officers of the board me being one of them OK and then given that the DMO is now going to be managing all this data which my understanding it UVM health network is the DMO is reporting structure is Rick Vincent going to have any what's his relationship to the data that then is going to be held by one care is this how does that work to kind of simplify it think of UVM health network is one cares vendor providing data and analytics so it's a purely contractual agreement between one care and UVM health network so to get back to one of Owen's questions then why would one care just contract with Arcadia what's the intervening step that the DMO does that they need to do so one care could hold its very own contract distinctly with Arcadia in terms of economies of scale that might mean that we have a lesser like we have to pay more of a PM PM to hold that payment directly with Arcadia so you have other contracts with Arcadia is that the no I'm just saying for us to have our own separate and distinct contract Arcadia versus buying a whole kind of suite of both tools and personnel would come at an increased cost for one care so what's the DMO doing what's the intervening step that the DMO does is between one care and Arcadia then you said you have the suite I assume the suite is the DMO part it's the tool and the people so Arcadia you couldn't just independently contract with Arcadia without having another layer of data management people at one care is that what you're saying correct but then there's people leaving one care to go to the DMO to do this job yes that's correct yes remember we're all UVMMC employees but now it moves it off from our financials as a direct FTE to a contracted service so maybe two points I could add one is that the general philosophy behind how the agreement is structured is that it's focused on the deliverables and the expectations not on account of the number of people so that's important because it's our board that's at one care that's really saying we want better analytics we want them to be more customized for specific audiences we want more flexibility around them and then the other reality just in terms of software in this field in general not speaking of anyone specifically is that a lot of their payment structures or their fee structures are based on volume so the more lives you bring in the lower a PMPM or a PMPY might be for those costs so ultimately we can leverage more buying power in any of these analytic services when we think about that combination of the lives that are not part of one care sitting in one place one care lives being under this sort of cluster agreement I guess the reason why I bring this up and I think we're all kind of hung up on it is the optics of this are kind of awkward and challenging I mean I think that if you put yourself in the shoes of someone who's not who's a competitor of UVM say for instance or a patient who sees a competitor of UVM for their health care now more consolidation of one care within UVM kind of creates a little bit of a concern or an image potentially an optical image of a concern that UVM and one care are you know working together to sort of to potentially benefit UVM I think what you're saying is that there are firewalls and protections and organizational structures to prevent that but I would imagine you could you could see that without this clear hearing or a clear idea that that is a surface it's UVM employees taking UVM and data surfaces under the CFO's management to aggregate quality and operational data throughout the whole state it just has it has some challenges to it I think that I I don't want to just optically I get that I totally agree with you that there's always going to be optical challenges and then there's the practicality of the fact that we put in safeguards to be able to protect against that and we could spend all day talking about what those safeguards are there's also their realities is that if one care Vermont went out and tried to do all of this on our own without the support of our sole member organization we'd have to hire our own HR team we'd have to hire our own payroll team we'd have to hire our own IT and security so we'd be bringing forward a budget to you that is way more than the current one that we're bringing right now so by aligning and sharing and not duplicating resources actually enables us to bring in a budget that's lower than would otherwise be if we weren't sharing these resources which would mean that our participating hospitals that are not UVM health network would be paying more for the services than they are right now because our budget would be even higher so there's the optics and then there's the organizational business of making sure that we're keeping our operational costs as low as we can so that we're good stewards of the state. I guess the one other thing that you bring up with that too is the organizational cost you have a really nice graph of them declining over time as a percentage do you have a similar graph showing the shared savings by your attribution as well if that's changed over time or if that sort of offsets if that's related to the attribution in the submitted materials there's shared savings earned year over year happy to consolidate it that would be helpful and is that kind of what you're asking? Yeah I guess the graph that you showed is really really helpful to see is there and I was just and I haven't I did look at the shared savings but I didn't look at as a percent of the total attributed lives or a percent of the total budget like you do with the graph of the total budget and I think that would be kind of a helpful visual to understand how successful you guys have been at sort of working with the various you know private networks towards shared savings yeah I think I understand what you're saying yeah I guess that's all I have for right now I thank you so much I'll pass it back to Owen Thank you just let's take a Cassidy how long of a break would you like? Oh five minutes would be great Okay we'll come back at 36 Thank you and we'll turn it over to Tom Walsh for his questions Thank you Thank you chair and thank you Cassidy for your help today Thank you for one care members for joining us and spending a long day of answering questions I want to turn to outcomes and process improvement if you don't mind what is the outcome measure that you believe best demonstrates the value that one care provides to Vermonters? I can't get myself off from mute I have an article too I would say that the federal government has created a national framework through the Medicare program to evaluate ACO's success in quality of care programs that follow care coordination patient safety and experience and overall chronic disease management and they also have a framework for looking at savings and losses per ACO so at an overarching level Vermont is no different and that we follow the framework that was very carefully selected by the federal government in evaluating the success of our programs year over year and we do that across payers I appreciate that I'm familiar with the framework I don't know that Vermonters are and there are concerns that the organization the accountable care organization is it's hard to identify the benefit I'm just trying to help with that a little bit from that framework what's the biggest the best outcome? If you ask a thousand clinicians you probably get a thousand different answers on what is the best outcome because they're all different I'm asking one care leadership I can take a stab at this I think there's a lot of different ways value can be measured since you asked for a number the two numbers that I think of first and foremost are 296,000 lives and $1.4 billion and I say that because what one care has done is put the care for those lives into accountable relationships meaning that the providers that care for these individuals are now accountable to quality I appreciate that Tom I don't need to have ACOs described to me what's the outcome that you believe has had the biggest impact for Vermonters well that's the one I believe I think that's what Tom is let me follow up with Tom please you believe that the number of lives covered is the best outcome what I was saying is that I believe having the care for these lives in value-based arrangements is a very positive outcome and absent one care offering these arrangements and programs the way I see it is that everybody goes back to their own corners of the healthcare system and does things the way they've been done for decades okay so what I'm struggling for is to find an outcome that would be meaningful to Vermonters and you may be able to say something like reduced ED visits and then I could follow up and say is that the same across all hospital service areas and you might be able to say no we have some that are underperforming some that are performing well and we're trying to learn from each other I could ask reduced ED visits is that the same for white and non-white patients those are outcome measures that matter to patients and I can't find them what I find on page 6 of your executive summary are things like we've made measurable progress including modifying coordination programs engaging stakeholders redesigning committees testing models and developing a plan that's not really what I have in mind when I think of measurable progress and it's like chair Foster said at the beginning I think we need to change a lot about the way healthcare gets done across the country and here in Vermont Vermonters deserve better I want one care to succeed so please keep that in mind as I work through these questions outcomes are first mentioned on page 49 of the narrative submission you sent to us and you outlined four categories of that you put patients into healthy, stable, rising risk, complex earlier there was a question and it was less than 10% of the patients in the complex bucket receive coordinated care somebody is defining that and saying it's coordinated care that didn't surprise me at all I don't think that's underperformance necessarily because they could be in the complex bucket because they're not getting coordinated care they're hard to get a hold of to coordinate care with or they have a hard time accessing services in our delivery system but I don't see what's happened to that number since 2016 I don't see any outcomes stratified by those groups I see a CMS report card for Medicaid ACO work and the overall grade on the report card is around 69% what's the correct action you're planning to take to improve that score Kerry I can probably let you speak to this but a lot of questions that you have surround providers ability to impact care and to change care delivery that's right it's not one of your aims to improve the coordination of care our job at the ACO is to provide them the data the analytics the supports the insights in the payment reforms to enable them to do that that's what one care does and that's what we should be evaluated on the outcomes our provider let me finish that outcomes are driven by our care delivery system which are frontline providers who are hurting from a workforce perspective hurting from a financial perspective so I would ask what is this system and totality doing to help clinicians deliver care just deliver care on a day basis so what we're doing is a small part in helping them in value base care arrangements I appreciate that and if one cares role was to support through data analytics maybe training some other things over time wouldn't there be improvements that we could point to if we looked year over year and it's been going on for five or six years wouldn't there be improvements that we could point to even if it's just a little piece and I think Carrie was showing some of those improvements that we've had in select measures and you also have to remember that we've been living in a pandemic for the last three years and so really evaluating while we've been living during a pandemic and care delivery has had to radically turn itself on its head just to deliver basic care for our patients I think that's an unfair expectations to put on our providers during a time that they've been struggling to take care of patients but Carrie I don't know if you'd like to say more about that as a front mind provider of care sure I agree with the last comments you just made there Vicki and Tom my answer to your question about outcomes when I think about what patients their families and caregivers want I believe we want wellness first of all and after that we would like access to care and granted not everybody wants the same kind of access we touched on that earlier but I do believe that most people want primary care access I think most people know that's where they're going to get the best care and help education and help staying well or being treated when they're sick I don't think people want to go to the ER necessarily or be in the hospital so I think people want more primary care they want their basic needs met which is why we're studying social determinants of health and finding out where that intersects with the quality metrics that we are working on and I think people want their care coordinated that's very different in my book than the general though that's a section of it but we all want our care coordinated we don't want confusion we want communication if we have a mammogram and it's abnormal I don't want to know that next week I want it today I want it tomorrow at least or as soon as possible so I think those are the basics that we want and I think that the support the data and the sports that we're giving our members are pushing in that direction we have been in a pandemic primary care access has crashed you know it's been a mess people go to the ER or they stay away from their primary care on purpose because they don't want to be exposed etc so it has been a hard time to measure this but going forward what we're pushing are these very things getting access in the right location being accessible providing coordinated care and also I think for primary care to move in the direction of team-based care is a big piece of this as well so that we have in the primary care home the components that our patients need access to they may need a behavioral therapist they may need a dietician and when that's all more centralized I think we can provide better preventive care and better sick care as well I appreciate that too and I understand that we've been in a pandemic and it's disrupted everything it's disrupted everybody's lives and most of us have family members that have been severely affected it's no small thing right I get it if there was a mature service organization following outcomes and working to improve processes we'd see tables and charts of where things were at the beginning what's the current system performance what interventions have we utilized and what's the performance now right what impact we've had then we could say oh we had a small impact but there was a pandemic I don't see things like that in your submission I see a lot of different graphs from a lot of different places and a lot of reference to federal government things but when we're trying to assess the budget of one care and being able to meet our charge the way that Dave outlined we need to be able to assess the outcomes and the improvements that the organization is meeting to justify the budget and I want to see those things but I don't I think what you're asking for Tom would require that we were in a stable state every single year so for instance our network and our attribution and our patients were different in 2017 then they were in 2018 then they were in 2019 and so on and so forth so it's not a straight line that we can be able to measure year over year because year over year we look different from our composition point of view in terms of both providers, practitioners and payers that attribute so what you get from us is an annual evaluation on the current state of affairs and what you're getting with a NORC evaluation is a more comprehensive qualitative and quantitative analysis of how the system is working and that's what they're being paid to do yeah I read through that carefully they do a good job and there were some promising things that were happening in the first couple years for sure they kind of flip around a little bit they talked about some reductions in ED visit utilization some more recent things looks like ED visits are higher so there's conflicting aspects but we can at least try to follow and talk about it when we have those outcome measures and it's I understand the composition of the participating providers changes that's not unique to Vermont before I did this job my other work was working some of it involved working with ACOs who are trying to form or trying to improve that problem isn't unique but they can generate outcomes and they can show process improvement and change in outcomes as a result you started to talk about key performance indicators in the submission what are your top three key performance indicators so we're working right now through the process I described with the UVMHSR team they did the research we have a set of 10 or 12 KPIs and they are going to our board to be reviewed and in particular we want to look at them in terms of their alignment with the Medicare benchmarking report I would say globally there's pretty good alignment but I don't want to be in front of our governance process and saying what those final measures are we'd be happy to follow up with you as soon as that conversation happens though that'd be great right you're here before us and we're doing the budget and it would and this isn't the first year you've been doing it and it would be part of preparing for this here's our performance indicators here's how they've changed over time here's our strategy and tactics going forward in the submission to us we had things the key framing questions about the KPIs with what's in our sphere of influence and what will best demonstrate our value or potential value those seem very relevant to one care but not particularly relevant to Vermonters meanwhile we're talking about six years in figuring out KPIs and whether they're in your influence or not or whether they'll demonstrate how good we're doing or not suicides are at all-time high in Vermont we've got ED visits according to the latest data that are 29 to 37% above those of comparison ACOs many of those suicide attempts or depression, anxiety people seeking care for that it's very difficult to get in to see a primary care provider or a psychologist often times you need to use telemedicine and go out of state to have access to those given the high rate of ED visits given the difficulties with mental health and substance use disorder does one care have an action plan to address those needs Terry or Sarah do you want to take that briefly we have an action plan to address avoidable ED visits built into our population health model and I already described that briefly we can come back around when we meet with you later on our whole quality update and give you more information about that and we don't have our own personal organizational project if you will on reducing suicide but we have had many discussions and some of the leaders are working together with other efforts going on in the state that we want to support we don't want to start something new there are efforts going on with the Department of Health with the Howard center etc we are in conversations with those groups and plan to join and provide our support there in a very you know real way not just giving you lip service I appreciate that and I'm glad we'll be able to follow up more about quality and I'm looking forward to that the ED visits the wait time issues part of one care's mission as outlined at the beginning of this meeting was addressing care coordination what role do you all see as one that one care has in addressing the wait times issue and Vermont there are as we talked about earlier wait times at all locations so are you talking about all those locations or just ER wait times right now I'm wondering if one care sees itself as having a role in helping address the issue of wait times across the state absolutely can you describe the role please I think the role is multifaceted depending on the care setting so and I believe that they've all been touched on at least briefly today so working with a consortium on providing some physician coverage for the SNFs because they're in a crisis with not enough physician care therefore throughput from the hospital to SNFs is has a roadblock so we're working on that we are incentivizing wellness visits in our population health model that requires people opening up access in the primary care home and getting their patients in for wellness visits that's child, adolescent and adult age 40 and up so those are some of the examples but definitely top of mind in all of our clinical work I appreciate you helping me understand more about it you talk about data analytics to support providers and in the narrative that you submitted you write that you're in the process of developing a survey for primary care providers and at this point the work in progress is to explore the practical implications of deploying the survey and increasing the response rate could you explain what exploring practical implications of deploying the survey means yes I'm happy to do that I took the survey and I helped to deploy the survey so we worked with the research group at UVM and there are we learned a lot a lot of lessons learned first time to do it we sent the survey link to leaders in healthcare throughout the state and asked them to ask their primary care force to take the survey so instead of sending out an email to the whole list we used other local healthcare leaders to see if they could send their primary care providers to answer the survey we thought that would be more effective I think it was more personal that's why we did it it was not effective people are busy I took the survey it took maybe 10 minutes but several people started it and stopped they either didn't like it or they got interrupted so there are multiple reasons why we didn't have more success as we wanted 80 responses throughout the state like Jessica mentioned earlier that's not a very high response but we had to do some extra calling to get that many people to respond so I sent some emails later to the leaders reminding them please ask your people to take the survey so many reasons why getting this off the ground wasn't exactly what we wanted but again we're learning from it and there were questions in the survey about what does one care do for you what does one care not do for you we didn't ask for written answers they were more agree strongly agree a line up of responses multiple choice so that also has its limits we would have liked to ask for some written responses but we thought this year let's just get a survey off the ground and get some responses going and learn from that so that's what we did I appreciate the explanation what was the response rate at this point the survey has only been partially analyzed so I don't have all the final we can share that with you later but as Sarah shared in her report out it did differ between at least so far on what we've analyzed it differed between independent primary care providers and those who are employed and I think you can probably figure out why yes what was the what were the rates I I don't have those off the top of my head the rates of response or the rates of like versus not like etc we can the response rates would be great you must know like how many you send out and how many you got back I don't know the total we sent out but as we said we got completed and a few more partially completed so I believe there about 80 being analyzed okay thank you so I guess what I would like to be able to do looking at the budget is to move beyond a simple assessment of the dollars health care is expensive if we were in our country we were getting we all felt confident that we were getting great service our lives were healthier we were living longer because of the health care we were receiving we'd probably be pretty happy spending a lot on health care and we spend tens of billions of dollars a year on pet food right we don't we're pretty wealthy country overall we that seems a reasonable place to spend money on health care but in our health care system as you all know and you're probably motivated to do what you do because you know some of this information our outcomes are mediocre at best but we spend more than twice as much per citizen as any other country and so we need to move beyond just the dollar amount to look at the outcomes that the work we're doing is producing and and six years in right I'd like to be able to look at a budget for an organization and see here's where we were when we started here are the things that we've been doing here's where we are now here's what we're going to do next and none of those numbers are ever going to be perfect there's going to be limitations and problems with all of them each of the time and we can have a discussion about that but we want to be able to see what's happening because of all that's being spent and that's very difficult to see with the material that you're providing to us I want you to succeed I want health care transformation but we I need to see more of it I like what here are the outcomes that matter here are our priorities here's our impact here's what we've been doing to address the systematic issues facing the state's health care system and these things can be rather simple when you break it down we we could be asking what proportion of covered lives of patients have diabetes what proportion of the patients with diabetes have an A1C level and the A1C level is higher than 9 that's already being done you've got those numbers the next step is to say what proportion of those patients have not been seen in the last six months of the patients who have not been seen what number of those end up in the ED or end up admitted over time and for any HSA within it the goal would be zero admissions and zero ED visits and the number of patients with an A1C level greater than 9 should shrink you don't need to benchmark to anybody else just show that those numbers are declining and getting closer to zero we need some type of measurement like that a final question this came up from listening today Sarah I didn't quite get it all so I'm hoping that you'll help me out one care is unique it's a statewide entity most other ACOs I think she said are more clinically integrated yes Tom the point I was trying to make is that when you look around the country ACOs vary tremendously in size many of them are aligned with their health system and work within that health system so there's much more interoperability of data and information and the point I was trying to make is that one of the ways one care is complex is that we have this statewide network lots of different organization types they all have their own EHRs they define things differently they calculate them differently they have their own governance boards that they're all accountable to sometimes the slowness of bringing people along and effectuating the type of change that we all want to see I guess takes more time and that's what I was trying to get at some of some of the data regarding successful ACOs across the country that fits with those they tend to be smaller they tend to be physician led so I'm wondering if I know I know this would be a difficult question for any of you to answer on the spot and so I'm not going to ask anybody for an answer but I'm left to wonder would Vermonters be better served with more smaller physician led ACOs and with that I'll turn it back to you chair Foster Thank you very much Tom and the last board member with questions would certainly far from least is Miss Lodge Thanks Robyn Thanks Owen Hi everyone good afternoon so I had a couple of questions about the CPR program development that you spoke to briefly earlier in the hearing and in your materials so specifically your materials mentioned and in response to the staff questions you mentioned that you're exploring how to expand the CPR program to hospital employed primary care and FQHC so could you give a bit more detailed status update on where that initiative is at and sort of your timetable of how you would see that developing Sure thing so for FQHCs we did a pretty deep dive with them actually it was leading up to last year's budget process and sounded like timing wasn't quite right for the FQHC group and they didn't have to take it up I think it would be relatively easy to apply over FQHCs some adjustments would be necessary because they're paid a little bit differently than independent primary care but I think the concept would actually hold true quite nicely so if FQHCs are willing to be a participant or a pilot site I'd take it up in a heartbeat for hospital employed one of the challenges that we ran into with this was the way primary care building happens within a hospital and they have a separation of facility charges from the professional charges that just makes capturing the actual primary care claims much more challenging it's even different between critical access hospitals PPS hospitals I don't think it's insurmountable but I do think that we needed to do a little bit more diligence in terms of understanding those dynamics to get it right and I think what I'd like to do during 2023 is some sort of a conceptual or shadow year with a few hospital employed sites because I think it would be great to really incorporate hospital employed CPR sites into our array Thanks sorry, it's going to take me a minute to get to my questions they're embedded in my binder so we have had quite a bit of discussion about the commercial ACO programs and movement there in terms of what I will call a misalignment of priorities between the provider network and the commercial payers I'm wondering if you have ideas or thoughts around how to build alignment as a state, not necessarily just for one care but as a state Good question, I think it's really getting every component of the state, the providers insurance companies etc on the same page in terms of what we're trying to achieve collectively and I actually, even though we haven't really succeeded yet in getting these unrecognized topics paving with commercial insurers there's more universal interest in doing it which I think is really good and now it's more in the space and let's figure out the details of it and that's where we've been hung up a little bit so I think there's some positive movement in this space and we intend to keep working with both of our contracted and commercial insurers to try and figure this out for next year we even talked about maybe if there's a mid-year arrangement that we could think about rolling out during 2023 so I think there's positive movement but we really had to get target models ironed out with them and then I think we do need to spend some time collectively on shared purpose, shared value of having fixed payment arrangements for providers Thanks. I wanted to ask you a little bit for more discussion about the blueprint for health and particularly around your new standard reports I may be out of date on what the blueprint is doing but they used to do standard reports to practices that was discontinued and I think now their standard reports are annual but I'm wondering if you could talk a little bit about your standard reports and how they either complement or not the blueprint for health data analytics that are provided since one of the statutory criteria is ensuring that there's not duplication between the ACO and the blueprint for health I'm happy to start with that question the blueprint reports as you mentioned have evolved over time as that's one care so lots of movement which I think is both very positive because it's responding to the requests and the needs of the network but can also cause confusion as documents are changing and people need to know who to expect it from and when so as we testified about last year and have since implemented we've really been focused on some new reports related to our quality measurement and our primary care panel management reporting getting those out into the field in a timely manner to inform current performance and incentivize the behavior change we want to see I think where we still have opportunities is that one care is a contracted network we have the ability to share data within that network and where there is alignment and overlap in a good way with the blueprint it makes it much easier so for example if a community health team administrative entity is a hospital and that hospital is in our network and there is a mutuality to the purpose of seeing the data that makes it easier to translate that information and use it for multiple purposes where there are distinctions that creates some challenges and we have not been able to independently solve those yet although we keep working on it and trying to evolve within the limits of data use agreements so in that sense I feel like what we're seeing in the community level is more timely information certainly the HSA consults that Dr. Wolfman's described and has been evolving are a really key central location for dissemination of particularly actionable information so what are we seeing in your community that is different worse potentially than somewhere else and what can you do about it and then we're supplementing that in some new ways with coaching between those sessions to really say okay you committed to do A, B, and C what progress have you made in that arena and what we're trying to do is really make sure that we're doing that in a complementary fashion with the blueprint with the priorities that are already established on the ground that we're trying not to kind of come in on top of those and I think that's more and more vital as we're all talking about workforce challenges and the need for reducing burden and better coordination one of the recognitions that we've had and what we've tried to leverage in our partnership with the blueprint is really around the quality improvement support so the blueprint has quite a number of quality improvement facilitators deployed throughout the state one care has two one in kind of focused in the north and one in the south to work collaboratively through that process not duplicatively so those are some of the tangible things that I've been seeing I'd have to get back to if you have more specific questions about specific data reports thanks I just wanted to get a sense of how that was going because quite frankly the lack of blueprint data I think has been a problem in general for the primary care medical homes in terms of the benchmark report I'll just make a comment that I would when you have developed your more in-depth analysis and key takeaways from that report I'd be very interested in learning more about that some of the data was not intuitive to me that certain things were high and other things were low in terms of utilization versus cost so having a deeper understanding of what's behind that would I think be very interesting and helpful in general we had some of the same observations which is why we're digging in yeah great in terms of Dulce in your submission you mentioned that one care is declining its contribution in the Department of Health I think is replacing that could you speak a little bit more about how that came about and the driving forces behind there sure we're really implementing a planned kind of progression that has been negotiated in place for a couple of years now and it came about really because one care when we first started the Dulce program it was kind of when we were in a phase and a mindset around short-term investments in innovative ideas that needed to be sustained by you know local community and providers and so that was the initial approach we certainly learned through Dulce that they had some great outcomes and that the system is fairly complex so meaning I think I spoke to this a little bit earlier it's not just something that you could cookie cutter move into all settings of care and yet everybody believes that it's something that has value in those communities it's serving so we started some conversations now a couple years ago with the director of maternal child health at the health department and really explored how that aligned with the MCH goals of the Title 5 grant and then what we could envision for a longer term and so with that last year we stepped down the first phase and then this year or for 2023 we plan to do that again but all of that said I think you know in parallel we continue to learn more and continue to engage around our SEOH to really think about the overarching system of care and what are some of the opportunities that one care can best influence thanks so it's a long-term goal then that Dulce funding would essentially move to the to VDH at some point or would you consider that to continue to be a collaborative venture right now I think we consider it to be collaborative we don't have a date aligned up with them that it goes to zero but it's something that we do need to continue exploring okay great I think actually the rest of my topics have been thoroughly explored which is one of the benefits of going last so I'm all set and I'll turn it back to you chair foster thank you I add to brief follow-ups based on my fellow board members questions on the benchmarking study has there been any effort or will there be any effort to normalize Vermont's results for the fact that we are a low cost Medicare state in fact the lowest cost Medicare state in the country so the data have already been normalized through risk adjustment and unit cost analysis the concept that one care is a low cost ACO relative to the others is foundational to the findings in the model and so no there is not a plan to readjust those numbers and I think as to doctor merman's point you know what we are trying to suss out is is this because of the ACO and the ACO's work or is this because Vermont is generally considered the healthiest state in the country and because we have severe wait times and access issues I mean obviously you can't get into the doctor at the volume you want the costs are going to be lower particularly if you're a healthy state so I think ensuring that data reflects those macro demographics of the state would be particularly valuable for us to evaluate it I think we can certainly look at some of those extra demographics that you're interested in I would also just mention that contextually there are tremendous number of environmental factors that we should probably consider if we want to think that we're comparing apples to apples so the amount of competition the number of urgent care centers you know how many sniff beds per capita there are there are lots and lots of factors out there which is why I think ultimately this provides some interesting and helpful information to us to see you know maybe where we are performing well and we're performing significantly worse and perhaps should put some energy in but ultimately the interventions that align with those areas of opportunity have to be thought about in the context of Vermont's health care resources and environment yeah totally I mean most reports you receive from an expert would have some sort of risk analysis based on the environmental factors for which you can't actually determine causation so I think a good report would have that kind of information for us to consider how strongly we should be evaluating what's in the report the only other question I had real quick is I think the CEO said something about the ACO provides data to enable providers to do things and that the ACO is a small part in helping them and this isn't you know one care can't fix all of Vermont's problems with its health care challenges right neither can the care board neither can PCPs neither can UVM there's a huge universe of insurance companies that have to figure this out together and from that perspective what I want to get a sense from your view is who is the most accountable if you do a hierarchy you have patients you have PCPs you have nurses you have RNs you have PAs you have doctors hospitals ACOs who should be accountable for results if you were to do a hierarchy who has the best opportunity to make an impact on what we're all trying to fix and I want to pay that person yeah I don't know if you're asking a question or making a statement so I guess that would be helpful it's a question what's your perspective on where we should be deploying our resources to the people that are most accountable for improving care and cost I think it all starts at the state and federal levels in terms of policies and procedures and how payments are made to providers I mean that's at the top level it's your governance for your state and federal government I want your perspective from your work on where the federal government or the state government should be deploying its resources at the level that makes the most impact well long-term that's prevention and so the money would be if you want prevention should be deployed obviously this is rough but it should be deployed to the patients and to their primary care providers it could be it also could be to the communities directly for providing things like you know sidewalks infrastructure and the community better benefits so everybody has food and housing security like it's all those upstream social determinants of health yet we don't invest in them as a country because they don't have those annual return on investments that everybody is looking to be able to measure year over year so until we as a country start looking at those upstream really upstream variables we won't be better off it's very helpful I appreciate that thank you for sharing that view that's helpful does anyone else have any views on this question great thank you all for addressing the board's questions we were in the staffs we really appreciate that and with that I'll turn it over to the healthcare advocate thank you Mr. Chair Mike Fisher here healthcare advocate I'm going to ask a few questions and then Sam will have a few questions thank you everyone for spending spending the day together and providing a lot of answers to a lot of questions getting to go last also I think shortens our questions and maybe some of our questions become follow ups to discussions that have already happened let me start with a recognition of some positives we you know again thank you for your presentation we really want to acknowledge and support your team's commitment to DEI work within your governance structure and the development of a disparities scorecard I think this is important work to step in the right direction we also want to recognize I want to recognize that we had a nice meeting with your patient family advisory committee look forward to that every year you have indeed assembled a group of consumers that have a lot of questions about how to make the world a better place I want to in follow up maybe to Marissa's point about the contract the contract between UVM and OneCare I heard the question I heard your answers I know this is complicated stuff it takes a while to develop I think I heard you say that it was signed up on November 1 but I do want to express frustration that we don't have that in front of us today I think we should have that in front of us today just wanted to express that it would make it easier it would help a great deal so I have a few questions about IT systems we at the healthcare advocates office are concerned about the amount of money that flows into healthcare IT systems this concern is not just about OneCare Vermont this is a much broader concern but because we have OneCare in front of us today there's a few examples with regard to Care Navigator we asked a question about how much Care Navigator has cost and you provided the answer in your written answer to us that in 2021 you spent $387,000 $387,500 on Care Navigator our question was I'm trying to back into how much was spent altogether on Care Navigator how many years was Care Navigator invested in by OneCare and is that $387,000 a good proxy for how much was spent per year Mike this is Sarah I don't know the number off the top of my head that was spent overall frankly we'd have to pull lots and lots of counting records to figure that out but I do think that that number we provided you for 2021 is a very fair proxy for what the annualized expenses were for the system and the customizations that we were adding year after year to try to make this work for our provider network thank you I'm not asking for a specific audited number by any means I'm not asking for a sense of it so would to get a proxy about how much was invested in Care Navigator would we multiply that by six literally going to count in my hand here so yeah six that makes sense okay so there have been quite a lot of questions about OneCare's new contract with UVM and so I want to try and fly a little bit high on this but we do have a few questions about it our non-UVM health network OneCare participation fees being used to fund the analytic work that OneCare contracts with UVM health network for yeah so Mike our model is that the hospital participants pay for our operational budget so anything that the ACO supplies is universally purchased at differing rates across hospital systems and you know the smaller hospitals with their net patient revenue obviously pay less than the larger hospitals too but they paid that for this isn't a new cost to them in fact this is the same cost to them as it was in the past and we're looking to get a better analytics tool out of this in the future okay there's been a lot of questions about the firewalls the data firewalls we're going to ask that question again I appreciate the high level description that you provided but I think we're all interested the healthcare advocates office is interested in much more detail about the separation of about the firewall but about what you just spoke to Vicki can you say a little bit about what motivated you to move away from health catalyst yeah so as we work through our strategic planning process it was unanimous that we needed to elevate our data and have access to better data analytics that wasn't so manual right that we weren't creating from our staff right having better data to be able to push out answers for our provider network because remember again we had we don't just have one organization that we're trying to take in data for we had about 170 organizations that we're trying to take in data for and so at the same time we were told by our board we cannot raise dues so we want a better enhanced system and we don't want to pay more for it because we can't pay more for it and so at that point in time UVM health network was exploring a population health tool because remember one care is just one value based care arrangement that UVM health network has across its enterprise so they were exploring some opportunities specific to value based care contracts and so our board said to us at that time why don't you explore whether or not there is opportunities to work with UVM health network use as Sarah talked about previously you know how large they are as a system and the pricing that would be available to them to get a enhanced tool for the ACO that would better support our growing data and analytics needs within the same cost contract because as you've seen our costs haven't gone up year over year in fact we've taken a precipitous decline in how much our operations cost are yet the accountabilities and the payment reforms that we have to manage and the provider network we have has been growing since we started so we need some pretty sophisticated tools to be able to manage that tension so for today and for a number of years one care has talked about its data and analytics as one of its core functions and in fact I think I think I've heard you say this is what you do well and something that you get to do that smaller hospitals really can't do for themselves I can't help but wonder whether I guess I end up with something of a similar question that I asked about Care Navigator but now about Health Catalyst there's something about what you were getting out of Health Catalyst for however many years you've been working with them that wasn't sufficient to do the work that you thought was right and so so I have the question about the money that's been expended and whether whether that was reasonable yeah I want to get the detail Sarah but I would say yes it was reasonable and remember technology has advanced since we first purchased Health Catalyst and so ACOs have come more mainstream and then there's been data and analytics services that have grown around ACOs right so it's always good you shouldn't just use the same vendor year over year you should look for vendors that maybe are more specific to the work that you do as an ACO but Sarah you work through the process of the RFP I'll probably have a more detailed description than I did I don't need to go into a tons of detail I would just add that our current system is not broken it's inefficient and it requires a lot of manual staff work to maintain and manipulate that information and it's in part because that particular vendor has chosen to focus on other priorities not so much in the ACO population health analytics space to date in contrast this other vendor Arcadia built that up quite a bit over the last four or five years and now has standard reports it has the data organized in ways that we think can be more efficient and effective over time it is going to take us some time to realize that so the focus that we've had is on making sure the costs are neutral meaning that we don't duplicate payments as we're starting to transition those and that ultimately we think that there will be some greater efficiencies we can't quantify them yet in the sense of like reduced staff effort to manually load data or to customize things to actually be able to use it that will come over time but I think we do have a pretty strong belief that it's going to be easier and better in terms of how we serve our network so just to give you a really practical example right now we have somebody who has to program some standard reports that we want to push out every month and then we have to have a staff member manually load them to a secure place where then we have to notify providers to remember to go get them in the new system there will be security in place that will allow non-PHI contained data to be reported directly into the email box of people who are provisioned to have that level of access so they'll get their summary report and then based on their user access they'll be able to click on a link to go get more information to help them close care gaps, manage populations etc so that's just one example of where we want to be heading to keep up with technology and its evolution. Just one more data question then whenever you do a transition to a different data system and you have to interface with existing data systems there's hiccups right do you expect there to be transition stresses for Vermont hospitals around that transition to this new data platform? The only stressor that I think is inevitable is the time it takes people to learn new reports and obviously it's our job to help support that but we are making sure that the reporting that they currently get will continue until the new reporting is ready and that people have had a chance to learn it and transition over and that was a fundamental concept that our board kind of set out as a guardrail so yes there will be bumps to your point it's inevitable I think one of the chronic bumps that we're always dealing with are data files that come in from payers that are not formatted correctly per the contract specs and we have to go back and over and over again have those conversations that's going to happen to a certain extent regardless of the platform it's really about how we manage those things and how we continue to work on improving them I'll leave this topic systems with a statement that from the healthcare advocates perspective we have a serious concern about how much money how much healthcare dollars go into data systems and continue to wonder whether we're not in any way opposed to data in analytics but continue to wonder about about just how much money flows into them and have concerns so with respect to Medicare and the increased population of people the uptake in Medicare Advantage it was we read in your in your budget narrative sort of that dynamic of the number of the increased number of people moving into advantage and its impact on you we also noted in your answer to I think it was a board question a recognition that I think you said one care data suggests that the population leaving traditional Medicare for Medicare Advantage has lower costs on average FYI that is a very similar finding to a description in a large insurers Medigap filing that the population moving to Medicare Advantage has a lower morbidity so this leads to the question and I know that we've asked this question before but we continue to wonder from one care's perspective whether the uptake whether this movement this movement of relatively healthier lives out of traditional Medicare and therefore out of your attribution is a good thing or a bad thing for the all payer effort and for one care's goals I think you kind of have to separate that a little bit because I always hate to there's the all payer model which the you know the state is the signatories to they have very specific goals and accountabilities under that and then there's the ACOs and one care is the only ACO that has agreed to participate in the states APM reform and I would say we need to look to the next agreement I don't think this is something that one care has the bandwidth to look at the Medicare Advantage over the next two years out of this current all payer model agreement into whatever comes next but it has to become part of our strategy at the ACO level to look at what programs make sense for us to be in not necessarily what programs fit the state's goals and responsibilities for scale targets if there are even scale targets that come into play in the next all payer model agreement I apologize I did not manage to say one thing in my original question that I just think is important to say out loud sort of in recognition of full transparency here OCV as a part of UVM is part of an entity that's offering a Medicare Advantage and I just think it's important to recognize that and I also appreciate that it's not within your bandwidth overall and maybe not at 342 after a long day to think about but but I think it's something it is indeed something affecting the Vermont landscape and I think also affecting one care I'm going to turn it over to Sam to ask a few questions thank you thanks Mike Sam Pish health policy analyst with the HCA I want to turn to page 18 of the narrative where you talked about the effectiveness of population health management activities will be assessed and I quote over the next three to five years I want to ask you to consider this from the perspective of a Vermont family that makes a typical median income that has a $15,000 deductible with real health care needs in their family and how you justify this to them I think as we've talked before Sam and been recognized by this committee affordability is not just the accountability of one care Vermont we have a small section of the population where but one cog in the wheel and yes there are other tools that can have more immediate effects were charged with population health management quality and total cost of care and so I totally hear what you're saying and I don't disagree with you in fact I I agree with you but I think that you have to look to the system and the other entities on how you make some more immediate changes okay thank you for that I mean I think the next question which is over the in the past we've heard you talk a lot about bending the cost curve and even reducing the per capita cost of care and it's notable that this seems to have been significantly downplayed and discussion of it really arose mostly upon questioning from Sheriff Foster today and we heard that one care performs better compared to national benchmarks on reducing cost but I want to point out that national benchmarks don't require these costs to decrease and they only refer to system costs not public costs formed by people like Vermonters like all of us do Vermonters receive any of these shared savings from these models or does it all simply flow to participating providers or are there any plans for these savings to flow to Vermonters in the future it all flows to participating providers and we have a model in the way that it's set up there are additional incentives that can be provided to patients that are part of the ACO and I think those do occur because you're allowed to provide incentives that you otherwise wouldn't as being part of an ACO that don't look at anti stark and kickback rules and things of that are occurring to individuals that are part of the ACO but it's not through shared savings I can add a little bit to that for the commercial programs where there's the most direct linkage between a patient's payment and the insurance coverage what we have actually seen in the past is that if one care of Vermont owes a shared losses payment for example back to the insurer that that payment back to the insurer is part of their rate filing for the next year so in other words it offsets some of the increase that you'd expect in the following year so I was very glad when I saw that that actually occurred and I would think that's an important thing that important dynamic in place with these commercial arrangements thank you for that that's helpful I know some of the questions today have focused a bit on evaluating causal impact so this is in that realm in your responses to our questions you wrote due to the complex healthcare reform landscape one care does not maintain a goal of determining definitive causality of its programs and I think we've heard today that the health system is complex I think we can all agree on that but I want to point out that this doesn't necessarily mean that causal analysis in this area is impossible or that it hasn't been done already there aren't methods to do this I mean I think we can point to directly acyclic graphs gray methodology difference in difference which NARC used among others so I'm wondering why none of these methods appear to have been utilized by one care in the past or if there's a plan to use these methods in the future to evaluate the impact of these taxpayer funded approaches to population health Sam thanks for the question I think the future is unknown but we have a particular new FTE that will be able to have some guidance to help us in that arena speaking to the past and kind of the present we have a fantastic group of analysts who are really focused on understanding claims data and clinical data and being able to turn that around into actionable insights for on the ground performance we did not hire them at the various points in time for similar types of analyses that's not to say that we can't advance or change things in the future but we've really been focused on trying to ingest all of this complex information, make sense of it and get it out to folks we have I think more to do as we've tested various methods frankly to mixed results in terms of what methodology makes the most sense to evaluate specific programs or even investments Thank you that's helpful just to follow up a bit of a comment on the causality piece not to harp on it too much but one concern that we wanted to raise is one of the guiding questions for the KPI key performance indicator work that member Walsh asked questions about I think we're all keen to learn more about was what metrics best demonstrate the potential value of one care and this I think strikes very clearly as a leading question that presupposes the existence of something that should be asked so I just want to make that point in the hope that future causal work proceeds from more of a null hypothesis style question but our last question on page 23 of the narrative it reads from the health care provider side commitment to payment reform and strong but their concerns related to the magnitude of possible commercial rate charge requests ensuring that approved hospital commercial rate charges are incorporated in the fixed payment amounts is essential for sustainability I'm wondering how one care reconciles these it appears to be conflicting messages very high large commercial charge requests and then hospital claims that these charges are needed for sustainability yeah good question there what I was conveying in that clause there was that every provider accepting a fixed payment will view fee for service as a reference point whether we like it or not and sometimes it's good and sometimes it's detrimental so to make sure that these payment reforms are effective and sustainable we do need to make sure that their improved rate increases are incorporated otherwise you know any hospital with this being a voluntary model would just say I can do a lot better in fee for service so making sure that there's a connection point there is very important and at the same time this is attention is not putting too much weight on variation from fee for service I think is something that will make true payment reform more sustainable over time thank you appreciate it turn back to you chair foster thank you for those excellent questions from the health care advocates office I appreciate that and the responses it is 351 and we still have public comment a little board business Cassidy how you holding up I'm doing really well if I could just ask quickly Mr. Prish what did you just say there you said the cycling pass methods at the end you were talking about that Narc uses oh yeah so there's an or I can actually remember the acronym but I can look it up but it's difference in difference I believe is what I was talking about what did you say exactly use two different it sounds like nouns for two different methods sure there's directly a cyclic graphs which I believe I mentioned and sufficient component cause model and then difference in difference modeling and okay perfect that's all I needed and yes I will need to recall my backup recorder at about 515 today and Mr. Foster but other than that I'm doing great I will certainly hope to wrap it up before then so I'll turn it over to public comment and for public comment please use the raise your hand function and I'll endeavor to call on folks in the order in which their hands are raised is there any public comment I'm sorry let me let me take a pause I actually need five minutes because I think I might have a technical problem with seeing there's a lot of people when we go off the record we can just come back at 358 and I apologize thank you off the record okay we're back on the record I had one more that I forgot to ask I apologize for chiming in with one more I'm looking at it's tab W in the binder appendix 6.1 balance sheet and there's a line that says due to UVM MC 2022 4.25 2023 3.797 I just wanted to understand what that was sure I can take that one so mention before that we're all UVM medical center employees so this particular line is the way in which we reimburse one can reimburses UVM medical center for the salary expense and any other expenses that UVM pays on our behalf so for example when UVM cuts payroll for all the staff we then pay UVM back through this to do from account to account to account to account I'm sorry to interrupt the flow and with that I'll turn it to public comment I think I've got this figured out if you can hear on the phone please identify yourself the first hand is ham Davis please go ahead mr Davis thank you mr chairman I've just got a couple of comments on this I've been to these meetings started going to this type the one I've seen over that whole period I'm struck by what looks to me like a huge air of unreality that hangs over the whole thing one care of Vermont is assumed to be the agency that's supposed to to control costs in the system that is impossible they have no power to do that no power whatsoever what they can do is and what they do do is they can give you a fixed price that you can contract which is the way you get the capitation which is the way the federal government and the health policy industry understand as a way to get the real cost containment they can't the people that can the people have the power to actual change costs is a green mountain care board itself they've got for the last year they've had in their website all kinds of data about problems that with Vermont health the non-UBM network segment of the system the costs in the UBM system on a cost per capita basis are the lowest and the quality is better than the rest of the system by a factor of two or three and so what I'm curious and we've just gone through the board not under this particular chairman just went through the whole budget cycle and not one single element of all that data that's been sitting there for a year was even mentioned so I just don't get it I mean the reality is one care Vermont one care Vermont can can get you know about 35 million dollars a year to each of the 700 or so primary care doctors in the state they will deliver they can they can construct a contract a fixed price contract with any pair who's willing to do it but they have no power none whatsoever to actually force any pair to do that the only people that have power in this system of the board itself thank you thank you very much mr. Davis fear for your insights in your comment and for participating in meetings like this for such a long duration it's really important and thank you is there any other public comment no other public comment which means I had anticipated there would be much and like a lot of my experience in this job I'm pretty bad at anticipating what happens and we'll come forward next so with that I do want to thank the one care team you guys were incredibly patient and thoughtful in your responses to a wide variety and assortment of questions I thought you did a really nice job of being candid and I appreciate that so thank you for doing that I think it informs the board a lot more of where we are and how we can help and hopefully it was a valuable process for you all as well your presentation I'm sure took immense time and effort to put together and had a lot of detail in the binder was very helpful for me so I want to recognize that effort that you all put in and thank you for it and internally I don't think people really appreciate this amount of work the staff does to get the board ready and under explain all this to us I can tell you there's a lot of late nights by a lot of staff members a lot of it because of me and others but I want to thank them publicly and acknowledge the kind of effort and work they put into this it's really really really impressive so thank you staff and with that I think we can conclude the one care portion thank you all is there any old business to come before the board any new business and is there a motion to adjourn so moved second all in favor please say aye aye aye and it sounds like there's none opposed and so the motion carries thank you all and the meeting is adjourned and thank you Cassidy