 Good afternoon everyone and welcome to the Green Mountain Care Board's meeting. My name is Kevin Mullen the chair of the board and we're going to start today's meeting as we usually do with the executive director's report Susan Barrett. Thank you Mr. Chair and I am in my car I'm actually about to go in and get my shot so I'm going to leave the meeting in about 15 minutes and come back in. So just a few scheduling announcements and public comment announcements. I'll start with public comment. As I've said before we are accepting public comments on a potential next all-payer model agreement with CMMI or CMS. And there's a link on our website under the public comment section. There are some slides that were presented to our general advisory as well as our primary advisory group by the Director of Health Care Reform at AHS Inabakas so you can use those as a reference. And then please submit those comments and we will be sharing those with our partners at AHS and the governor's office as they will be taking the lead in a potential next agreement. And the scheduling announcements are next week I think will be a really interesting meeting. We are going to have an intro to the Data Governance Council an introduction of the members. We haven't had a chance to have all of you at the Green Mountain Care Board have a direct conversation with that subgroup the Data Governance Council of the Green Mountain Care Board. So I think that will be a really great opportunity for you to get to know them as well as the public. And then we're also going to have a potential vote on the data submission rule. And then there is a prescription drug technical advisory group on April 19th. I see Robin shaking her head member lunge at 2 p.m. I think that's correct. And all of the information to get into those calls are is located on our website. And that is all I have to report. Thank you Susan. Good luck with the jab. Okay. The next item on the agenda are the minutes of Wednesday April 7th. Is there a motion. So moved. It's been moved by Maureen and seconded by Tom to approve the minutes of Wednesday April 7th without any additions deletions or corrections. Is there any discussion. Hearing none. All those in favor of the motion signify by saying aye. Aye. Aye. Those opposed signify by saying nay. Let the record show the minutes were approved unanimously. Next we're going to turn to a discussion of the vital budget guidance. And for that I'm going to turn the meeting over to Sarah Kinsler. Sarah. Thank you very much for the record. This is Sarah Kinsler Director of Strategy and Operations. A few weeks ago I presented to the board some draft annual budget guidance for Vermont information technology leaders. The goals of the draft guidance are to provide clarity to the board and vital about the regulatory timeline and the contents of the budget package as well as clarity around monitoring activities to provide clarity to the board and vital about about those monitoring activities both like the quarterly updates and the mid-year budget to support collaboration between the board's staff AHS, DIVA and VITAL and to clarify the board's principles review for review which have not been updated since 2016. I wanted to report back to the board that we received one public comment about this. The comment was from VITAL in support of the draft guidance as it as it was presented. And there were no other public comments so I'm not proposing any changes to what was presented a few weeks ago. If the board would like I can present or I excuse me I can project the draft guidance for you all now. But I think there are no other there are no other changes that I would recommend. Okay do you need a motion from us Sarah. I do need a motion if you if you are prepared to vote. I can make a motion. Go ahead Tom. I move that we approve the vital budget guidance as presented to the board on March 31st 2021. A second. It's been moved and seconded. Is there further discussions from the board or questions of Sarah. Hearing none I'm going to open up the topic to the public for public comment. Is there anyone from the public who wishes to comment. Seeing no hands raised and hearing no response. Is there any further discussion by the board. Hearing none. All those in favor of the motion signify by saying aye. Aye. Those opposed signify by saying nay. Let the record show the motion carried unanimously. Thank you very much Sarah. Very short. Very concise. Okay next on the agenda we're going to turn to Act 159 of 2020 Section A. Hospital Hospital Sustainability Planning. And I'm going to turn the meeting over at this time to Alayna. Alayna Barabee. Hello thank you. Okay so I will share my screen. Let me know. We can see it. Great. Okay so this report was submitted to the legislature on April 1st and I will pick and choose what I think is the most key for us to review today. So this is just a reminder the statute asked the Green Mountain Care Board to consider ways to increase the financial sustainability of Vermont hospitals in order to achieve population based health improvements while maintaining community access to services. As a reminder the context within which our health care reform is happening is value based care so the slide should be familiar to you thinking about not just cost but also quality and population health. With the patient being in the middle. Patient at the center of that care absolutely Chairman. So this slide just we've used it in a number of presentations but kind of synthesizes on the commitment of the you know the federal commitment to making this shift to value based care. This really began in 2010 with the Affordable Care Act was kind of reconfirmed with MACRA and existed and maintained momentum through changing administrations and then you know has been evident as a continued pursuit of the Biden administration with our most recent change. And in Vermont we've also seen commitment to shifting away from fee for service towards value based care for many years you know starting back in the days of blueprint and then through the SIM grant and as evident as well in our all payer model. And then the global commitment for health waiver also has intersections certainly with the shift to value based care. So it's you know just this is an important context to remember when we're thinking about sustainability it's really not you know we're not trying to focus on fee for service but really kind of sustainability in a value based care environment. So I want to revisit some statutes that may be very familiar to you but wanted to point out kind of some additional goals that you know are important to consider as we're moving forward in this work. So you know the purpose of the Green Mountain Care Board was really to improve health of the population reduced per capita rate of growth and expenditures for health services in Vermont across all payers while ensuring that access to care and quality of care are not compromised and then enhancing the patient health care professional experience of air recruiting retaining high quality health care professionals and achieving administrative simplification. So certainly no small fee but all still very relevant to the work that's happening in our city. Some health care reform principles that are very salient to this work you know I think there are three key principles that are most relevant. So you know reducing the overall health care costs so cost containment. Item number four is about you know continued access particularly in rural areas to necessary health care services and that these health care services are sustainable. And then principle number 12 that the system must consider the effects of payment reform on individuals and on health care professionals and suppliers. It must enable health care professionals to provide on a solvent basis effective and efficient health services that are in the public interest. So taken together you know I think we really just I wanted to highlight here that although we're you know we're focusing on hospital financial sustainability it really cannot be studied absent these other policy goals which are so tightly intertwined you know with access and affordability. So some of the Green Mountain Care Board's duties that are you know directly related to this work as well you know our regulation of innovative reforms that seek to improve statewide performance on cost quality and access as I mentioned before. So we use regulatory levers to contain Vermont's health care cost growth including the development and implementation and evaluation of health care payment reform. Develop and implement a method for evaluating systemwide performance and quality including the identification of appropriate process and outcome measures. Identify Vermont's critical health needs goods services and resources in the HRAP. And then through hospital budget review process about the efficient and economic operations of hospitals consistent with HRAP taking into consideration appropriate benchmarks and best practices. So these are things that the board does that kind of supports this idea of hospital sustainability planning work. So what are the you know again what are the problems we're trying to solve again as I mentioned it's not just financial sustainability but you know eroding hospital margins and their root causes is certainly one of the key goals here. But also you know in order to ensure that the margins are sufficient what are we what are we paying for right what what is the system by. So opportunities to improve health system efficiency and to ensure continued access to essential services. We don't want to you know pursue hospital sustainability to the detriment of access. So these things must be balanced. And then also the unaffordability and unsustainable reliance on commercial rate increases as they relate to hospital budgets. You know I think sustained or unaffordability is something we've certainly heard a lot about over the you know over the most recent years and continues to be a critical problem for Vermonters. And then preparedness for value based payment. So hospitals cannot continue to rely on volume centric business models and rely on fee for service to catch back up and make their their budgets whole. So how do we kind of prepare our hospital system for that shift to value based payment models. And then COVID. So our pandemic you know was was really you know wasn't the reason for a lot of these issues but certainly exacerbated and could many of the financial crises that some of our hospitals were in. So how do we help ensure that hospitals can recover post pandemic and not just you know in terms of financial challenges but also how do we help being ensure that they can get through their backlog of preventative care and screening that may have been foregone during during the shutdown. So I won't spend much time on the hospital financial measures because I think you know many of these are very salient to you now and the hospital team did an excellent job not too long ago taking you through this. But you know just just as a reminder you know we've had hospitals. This is not just a Vermont problem. This isn't a national issue. But we've you know close to home have also noticed you know we had a hospital bankruptcy and then increasing or decreasing margins has been certainly troubling. So this work has been ongoing and as you know is is still a great concern. So I'm getting operating margins even before COVID-19 where we have expenditures outpacing revenues you know and this only got worse as you can see in the right most column with the pandemic you know essentially eroding margins down to zero. In operating margins it's not just you know one or two hospitals. It's really across the board at least seen these challenges. They did get some federal support but that is you know not expected to be ongoing. So I will continue through here. You know as I mentioned the federal support while that helped you know it's not a sustainable model to continue to rely on non-operating income. And that's you know commercial charges continue to increase. So while you know there there may have been some assistance that helped kind of get hospitals through this through this challenging time you know commercial rates continue to rise and that is not sustainable. So I think it's it's really important to define the work as you mentioned before kind of the the broader context within which we should consider financial sustainability. You know how can we ensure that hospital revenues or provider reimbursements are sufficient to cover the cost of operating a system that strikes the appropriate balance between efficiency and access in rural Vermont. So you know it's certainly important to recognize that in a small state where we have declining and aging population that is dispersed throughout the state that we we do have to pay a premium for access in those communities. But how can we kind of ensure that we are as efficient and clean as possible and at a system level. So it's certainly possible that we can operate efficiently on the community level but there may be some opportunity still in the name of continuous improvement to continue kind of thinking about creative ways to make sure that we have the most efficient system possible and that we're we're using our our limited resources efficiently in this So how can sustainable hospital reimbursement ensure access to essential services all Vermont communities. How can we ensure the efficient and economic delivery of services and ultimately the improved health outcomes for Vermonters. So the framework this should look familiar to you. I think the sections may look a little bit different but we've all of the content is still very relevant and similar to what was presented last year. So part one is now a current state and gap analysis as you know we had hoped that this would be a collaborative exercise with the hospitals and it and it has been. But I think you know due to the pandemic we've not been able to kind of have that upfront engagement that we were hoping with the depth of upfront engagement. And so you know we took a lot of that kind of data number crunching in house to see how far we could go and anticipate kind of further conversation with our hospital partners as they as they have some capacity to do so. So this current state and gap analysis looks at hospital financial health provider reimbursement and variation in prices and costs. Community access to essential services and hospital system needs to improve health outcomes of Vermonters including an assessment of hospital system capacity and quality. So these analyses kind of taken together should give us an idea of kind of the challenges and opportunities that may lie across across our state. Part two we really hope to get deep into hospital engagement and kind of fleshing out you know what what these analysis are pointing to and then further analysis that made me needed to kind of tell the full story. And then part three we hope that you know through those learnings we can identify some potential paths forward to improve hospital sustainability and preparedness for value based care taking into consideration those other policy goals you know of affordability and access that we discussed earlier. In the hospital financial health you know we got some great feedback from some of our hospital leadership when we were speaking with them last fall. I think everyone felt that the measures and benchmarks that we were discussing were pretty standard and were but indicators of financial health. So you know once we can kind of package all of the analyses up we'll ask hospitals to explain the drivers of the identified vulnerabilities any hospital led strategies they already have in place aim to mitigate these challenges as well as any known state or federal barriers to these kind of identified vulnerabilities. So you know this we feel pretty good about and already have made some significant progress. This is an example of the dashboard that was created using hospital financial metrics that we already have access to through the hospital budget review. And so you can see across the bottom there are a number of tabs and kind of groupings of indicators and it's an interactive dashboard that can kind of give you an idea of how hospitals are doing on these particular measures. And there's some explanation up front about what these measures mean. So no single measure will kind of tell you the whole story. It's really about kind of triangulating across different measures and I think both financial metrics and kind of the capacity and quality metrics should be considered simultaneously and we'll kind of get into that. So some of the next kind of content area in the current state and gap analysis is hospital reimbursement and variation in prices and costs. So this section describes kind of the business model of the hospital and their ability to kind of generate a margin. So the percent of hospital revenue from value based payments and then kind of I think as you've seen in the hospital budget guidance here getting some more clarity on different kinds of value based payment programs one of which we think is particularly beneficial that you know you all have been discussing at length is the fixed perspective payment which provides stable and flexible payment streams to providers that can be kind of invested up front rather than waiting for kind of utilization to occur and paying on that fee for service basis. So and then cost and price variation by hospital. We hope to look at that by payer hospital designation and then inpatient outpatient down onto the service line as well as a payment to cost ratio by inpatient outpatient and kind of the service line level. So this will be new information that will get us a better idea of kind of the business operations and challenges and variation really across our different hospitals and hospital district. This is an example of one of those analyses. So you'll have kind of groupings of different hospital type and then variation in cost or price. Quality so access and we will also assess the ability of the Vermont health system to deliver essential high quality services and improve health outcomes for Vermonters by assessing capacity and quality. So on the capacity side, we're going to look at, you know, overall occupancy rates for Vermont hospitals relative to peers, trends and ED usage, inpatient admissions, length day and then we'll project the bed needs given, you know, some of Vermont's demographic challenges over the time horizon. So these are just some example indicators of the types of metrics we'll be looking at just to get an idea of some trends. And I certainly don't preliminary capacity analysis will answer any, you know, all of our questions. We it will work. It's just kind of a conversation started to begin to understand the challenges that our hospital system faces. So this is an example analysis, you would have the kind of the hospitals across the bottom. Each of these bars represents a certain hospital and will show you, for example, their outpatient emergency room rate, you know, compared to the Vermont average and New Hampshire average. And we have a Maryland average, though some some peer benchmark and then projected bed need by hospital. We're going to look at, you know, you know, total sorry, total days. I've already I'm just been blank, but so you're looking at average daily census based on historical use. And then modeling kind of what the population projections may look like across our communities and then what, you know, out, you know, a number of years that might look like. In terms of quality, we'll look at in hospital mortalities, intra hospital readmission rates, complications, prevention, quality indicators, service line volume analysis, among other quality indicators in this quality section, particularly excited. You heard not long ago from VPQ and we're doing some exciting work with them to try to think about how we can kind of coordinate across our quality frameworks and make sure that, you know, this is how we're thinking about qualities in line with the work that's already happening in our hospital system and then how we can kind of improve in a line across quality frameworks. So an example of some quality metrics from our analysis is, you know, in hospital mortalities, you have the hospital names across the bottom and then observed versus expected rates. We also look at intra hospital readmission rates, which is, you know, between hospitals. And that'll be that kind of the first time we dig into those kinds of statistics using VPQ, which will be pretty interesting. Another one is this could this could be a hospital specific dashboard. It has, you know, different service lines in each of those kind of grouped columns, and then the observed and expected mortalities for that particular service line. So there's very granular data and very kind of aggregate data. And so it'll be important to really understand the narrative and have discussions about what what these data might mean and how what we can learn and how we can think about evolving and improving efficiency and quality of our system. And so hospital engagement, you know, as I mentioned, we we have worked with hospitals to the extent possible, given given the pandemic and their, their, you know, their need to spend, you know, spend most of their time in their community dealing with the pandemic on a daily basis. So we did have CFO meetings in December of 2019. So this is before, you know, the bandwidth problem arose. And that did inform kind of how this work got started. We had staff presentations and public comment February and July of last year, which is very helpful. And then hospital leadership meetings, October November of last year. And we received quite a bit of very helpful feedback influence kind of where we took this project next. And then as I mentioned to alleviate administrative burden, we really tried to kind of push this work as as much as we could on our own giving existing data and contractor support. So next steps and certainly all contingent on the pandemic is, you know, we hope to work with hospital leadership to review the analytic methodologies employed. And these analyses so far continue discussion discussions with hospital leadership to keep in our understanding of community specific nuances early insights. And then continue their work with VPQ to ensure aligned approach to quality. And then we want to share initial insights and analytics with hospitals and ask for their engagement discussion on these sustainability potential solutions and then share access to high quality essential services and improvements and help. And then part three potential pass forward. So, you know, at the end of the day, all of this discussion and this analysis we hope will point to some areas to improve hospital sustainability, maintain access to essential services and continue to improve health outcomes, given this shift to value based care. So whether and how can we evolve the hospital budget process? Are there opportunities to improve other regulatory processes? And what do these insights and challenges suggest? Or, you know, Vermont's proposal for a subsequent agreement or other value based payment models? So, you know, we're not anticipating kind of directing specific hospital strategies, but rather learning from the challenges that hospitals are facing, the strategies they've employed and that can employ on their own versus where they need kind of a system wide approach. And how can we think, you know, strategically and system wide about some of these solutions? This is just kind of a summary of the timeline to give you an idea. I think we've talked about a number of these timelines. We had our first update to the legislature last November. This presentation was served as the update for the April 1st deadline in the statute. And then, you know, the final report is due back to the legislature September 1st, but no later than November 1st, depending again on the pandemic. So, you know, it still feels tight given that timeline, despite all of the work that we've been doing, but we will continue to kind of go as fast and furious as we can while being thoughtful and look forward to engaging with our hospitals and communities to continue to learn more and evolve this framework. And that is all I have for you today. I will pause and take questions. Thank you. Good to see you back in the office. Yes. Here. So members of the board, questions or comments for Elena? This is Robin. Thank you, Elena. I thought very clear presentation and it's good to get an update on, you know, where the work is and how it's going. It's I'm very interested to see the results and to think about how we can move forward from here. Great. Thanks. I have a couple of questions. I should remember this, but I don't. Are all 14 hospitals participating in this process or is it just the six? Yes. So actually, I should have paused there on the timeline. You as a board voted to extend it to all hospitals, they believe last budget hospital budget cycle. So now it is all Vermont hospitals. And just not to get into any specifics, but our do you get a sense that all the hospitals are in this, you know, truly collaborative manner? I don't want to speak for the hospitals. I think, you know, we did feel that there was a lot of collaborative feedback when we were meeting with them before. I think, you know, we have a couple of meetings coming up, and I'm hoping that, you know, we're all going to come with with ideas and with with good intentions. But yeah, so I'm hopeful. Well, in fairness, Tom, to them, you know, they've been dealing with the pandemic. So I was very called to to get, you know, jump head first into this process. So I fully understand that. That's why I asked the question just because I was not up to date as to, you know, is to the reaction to both this and the pandemic. And I knew that that was an issue at one point in time. Can you go to slide 23, please? So my question here is just whether or not timing of variation and prices is are kind of aligned because here we have have this issue in the sustainability process. But we also have before the sustainability process was even born, we had a price process internally using the cures and and discharge data having to do with price variation. And I'm just wondering whether or not the two of these are aligned so that that this process will be informed by our more internal process and that you'll have a very strong database with which to work with hospitals because my my guess is there's a lot of will be a lot of interest in this area. It could be controversial. And so I'm just trying to make sure that that the two ships aren't passing in the night here. Absolutely. And, you know, we've been working with our hospital or sorry with our analytics team on this. So I think all the necessary alignment, you know, we can we can flesh out, you know, where and I'm not I'm not intimately familiar with the other work. I wasn't on that project, but, you know, we'll make clear, you know, any caveats between analyses that may be relevant. But I, you know, I, you know, this is one area that we'll be reviewing with our hospital leadership. This is because it uses claims tells, you know, part of the story, but we really want to understand kind of how much of the story this tells and I think those conversations will be really important to understanding how this data should or shouldn't be used. Yeah. Well, I, you know, I know that the auditor Hoffer did an analysis a while back that that basically implied that the size of UVM Medical Center put them in a favorable negotiating position with with insurers, which may or may not be true. But the price variation data in this process and that independently going on with our analytical team, I think will be very valuable to kind of sorting through what's real and what's not there. Yep. And final, finally, I'm just, I'm just wondering how structurally that you see this unfolding, because this is more than a one year path. And, and so how do we take this initial work and boil it down to the essential metrics that we have to look at and, you know, structure structure that in our budget process over the next two or three years, because I can't I just think it's too much substantively to deal with in one year. Yeah, I think that's a really good point. And I think there's going to be a lot of rich data here for us to consider and to look at to learn from. But I don't think we will be able to boil it down to any particular metrics. I think what we're hoping is that this will be a learning opportunity to think about, you know, where we could go next. And I don't know exactly what that looks like, because I we haven't kind of done. We haven't finished that analysis, right? So but I, you know, we're hoping to learn and to kind of, you know, maybe there's some further, maybe there's further research that needs to happen. Maybe we don't have all the data we need to be able to answer some of these questions. I think we some of these metrics may be so helpful that you might want to consider them in your hospital budget process. But I don't, you know, I don't have those answers yet. But I think we're kind of weaving the door open for that learning to happen. Great. Thank you, Elena. Other questions or comments from the board? Hearing none, I'm going to open it up to the public for public comment or questions. And I'm going to recognize Dale Hack at first Dale. Yes. Thank you for the presentation. I followed it the best I could while it's also trying to multitask. So forgive me if I ask a question you actually answered. That seems to be the way with Zoom, you find yourself doing more than one thing at once, especially you're trying to follow the legislature too. So it sounds too smooth. I'm unless I'm missing something because of the pandemic, I see where we're trying to go. And I also know like with the all kind of model and the global commitment waiver, those are coming up for renewal. And some of the particulars around that actually haven't bothered. I'm wondering how that's going to work out. Especially if you're at and you're looking at data about what's utilization, but the pandemic is going to our increase utilization down the road as you try to catch up on services that weren't delivered. That may not be just a six month. And then we're back to normal. That could be a year. It could be two years. We really don't know. We don't know how sick people actually are are going to be from the pandemic. How does that all work out? I mean, I see a future where you may actually be in a year's time be not wanting to cut utilization, maybe having to define essential utilization. And if you're running into a cap, you're going to be trying to reduce reimbursement rates and still carry the same utilization. So I'm not I don't have all of those answers where you deals, but I think this is a really important point that we have to consider. So, you know, the data that we're using is from pre pandemic. So we certainly recognize that the pandemic added a number of complications to understanding trends going forward. So that certainly something we'll have to think about. Okay, so it's a work going forward where we really don't know if we're going to find out. Yes. Okay, next, I'm going to call on him, Davis. Thanks, Kevin. My question for Elena is that one of the things the elements you had in the quality layout, the bash dashboard or whatever you call it was. Thank God, many years, and I don't think I'm curious why you're not using the inter hospital readmission rates because those are the real ones in Vermont. I've seen this happen a dozen times. If somebody has a needs to be it gets a surgery that doesn't work, for example, and they get it, then it does not just small hospital involves big hospital. Somebody goes to UBM and they get them and they get a bad result. Then I go back to UBM, they're going to go to Dartmouth. Same thing. So my question is, my question is, especially for surgery, real issue in admission rates is not in try. It's in turn. And I just do not understand why we can't see those numbers. Ham, I'm glad you raised that because I meant I meant to mention that. So we are looking at both inter and intra hospital readmission rates. So we can, you will expect to see that. Thank you. So, Ham, you're breaking up. I'm not quite sure what you just asked. I just want to ask one more question. Go ahead. Okay, okay. Elena, this whole sustainability exercise is obviously very important. Can you give us a report on when we can likely to see what the two consultants that you have had in the field, they were supposed to report in February? When do we begin to see those numbers? Do you know? Thank you. I don't know. I think we have some preliminary. We've had a preliminary look at some of the analyses. I think we want to kind of review that and make sure that we're understanding exactly what that's saying and what we can and can't say about it. So, you know, we hope to release it as soon as we can. But I think there's still some work to do there. Thank you. I'm done, Kevin. Thank you, Ham. Next is Kathy Fulton. Kathy. Good afternoon. Thank you, Chair Mullen. And thank you, Elena and team for the great presentation this afternoon. I just wanted to share two thoughts and just really appreciated the detail of the descriptive statistics that were presented as part of the draft reporting. And I just want to add a thought that on the flip side of those statistics are some of the realities of the stories and challenges behind those numbers. And what comes to mind are, you know, length of stay and related to, you know, what could be very isolated but challenging and difficult discharges because of lack of facilities and placement sites and appropriate appropriate and safe discharges. So, you know, one or two challenging cases can really skew the numbers. So, you know, we're very excited to be working with Elena and Michelle and the whole team to really understand the meaning and some of the interpretation of the data to convert that to valuable information. And really just to reinforce along with Elena, I believe you said this earlier, this entire process is our, I think, initial steps in becoming a very strong learning health system. And I think it may address some of what Dale was saying. You know, we have to go through these probably somewhat painful initial steps and gather in the data, use our communications and the strength of our relationships to then convert that data into meaningful information that then can really drive our decisions forward. And as a learning health system, it's wash, rinse, repeat. We keep doing it over and over and over and just keep refining the system till we get to where we feel comfortable and strong in our performance. So thank you for this presentation today and we look forward to the continuing collaboration. Thank you, Kathy. And thank you, Kathy, for the collaboration on your end. It's always a pleasure to work with you and your team. Other members of the public, other members of the public, I'm seeing no hands raised. So if anybody has comment, just speak up now. Otherwise, I'm going to thank Elena for her presentation and know that this work is ongoing and that we look forward to getting more involvement from the hospitals as we move forward. And as we begin to validate some of the information that as Elena said has preliminaryly been prepared, and as Kathy has pointed out, there are always more questions and to get to the truth, it's not always black and white. So with that, thank you, Elena. And we are going to move to the next item on the agenda, which is an update on the all payer accountable care organization model agreement implementation improvement plan. That's a mouthful. And we're going to get that update from Elena back as from the director of health care reform for the agency of human services. Elena, welcome and glad that you're here. Hi, thank you for having me. I also would like to introduce my colleague, Wendy Trafton, who's the deputy director for health care reform at the agency of human services and invite her to co present with me. Super. Hi, Wendy. Hi, Chair Mullen. Thank you for having me. In order to provide an update for the board on the implementation improvement plan, I'm going to use the source document itself, the actual appendix in the implementation improvement plan that serves as a compendium of recommendations that we made. And if it's okay with you, I would share my screen in order to do that. That would be great. Are you able to see what's going on? I don't see it yet. Does anybody see it yet? How about now? Yes. Great. As you're familiar, because we worked collaboratively, we to address the scale target warning that we received from CMS back. Now I can't keep track in our new frame of time given COVID-19, but I think it was in the fall. We received notification from CMS expressing their observation that we had exceeded our scale targets in our all-payer model agreement. And we worked collectively both through this process of establishing an implementation improvement plan, but also in providing a response to CMS to detail how we would look to improve the performance in the all-payer model. I wanted to make sure if you had discussed it that your audience knows that we did receive a response from CMS that accepted our recommendations for working to improve scale. So that is a positive development. Many of those recommendations are the same as are here in our implementation improvement plan. Our first recommendation in the implementation improvement plan is to negotiate with CMS to revise the scale targets to reflect realistic capacity for participation. And in terms of an update on where we are with this recommendation, CMS has in my estimation indicated that they are willing to come to the table with us to talk about a potential modification in this regard. As you also know, they are settling into a new federal administration and settling into some very recent new leadership. And so I would expect that hopefully in the near term of the spring and summertime that we might be able to have these types of conversations more seriously with them. The next recommendation that was proposed was to reduce thresholds and decrease the financial burden of participation for hospitals in this model. And then your staff and this board is very familiar with this recommendation because of your key work in bringing it to reality and working with CMS as co-signatories on this agreement to make this happen and get this across the finish line. So this recommendation has been has been we have made we are not in progress on this recommendation rather we have implemented this recommendation fully. We also have requested that CMS establish written guidance or best practices on cost reporting for critical issues. We have also requested that CMS be able to have these hospitals and again consistent with the CMS and CMMI particularly settling into their new leadership. We do anticipate that we should be hearing something from them on this front. Again in that near term you know like spring or summertime in a couple of days from now. Hopefully it's still well. We also we also recommended establishing a path for the Medicare payment model to mirror Vermont Medicaid next generation fixed perspective payment. With this recommendation and I would like to say that this recommendation really is emblematic of the frame that we approached the implementation improvement plan from being that we have seen as you are familiar considerable participation in the Medicaid program. We have seen quality improvement in the Medicaid program and we have observed the stability and predictability that the true fixed payment component of the Medicaid program has provided for participants in it. And so much of this implementation improvement plan theme throughout it is really trying to replicate that success with the Medicaid model in the other pair aspects of the all pair model agreement and implementation. This path for Medicare payment to mirror the Vermont Medicaid next generation fixed perspective payment our work here similarly we need to come to the table with CMS with their new leadership in place with CMMI in particular and discuss this recommendation certainly this recommendation is important relative to the implementation improvement plan which is for this current agreement and potentially for a potential possible successor model So again this is a place where we expect there to be some more significant conversation with CMS in the coming months. Recommendation number five to ensure that the Medicare benchmark provides as much stability and predictability as possible relative to 2021 and acknowledging the uncertainty associated with the pandemic I think that this work has really been led by your team at the Green Mountain Care Board and that this recommendation could be considered complete at this time We also again want to collaborate with CMS and CMMI in particular in encouraging HRSA to prioritize value-based payment for federally qualified health centers This is a longer term recommendation but still one that is important to discuss with CMMI in the near future as we're talking about how we can really maximize our performance in this model and also because there is significant opportunity for participation from federally qualified health centers and in thinking about how federally qualified health centers as well as hospital-based primary care are working with independent primary care perhaps are participating in more prospective payment that provides additional flexibility and ability for practices to better serve their patients Recommendation number 7 is for AHS and the Agency of Administration to conduct education and outreach to non-participating self-funded groups about the benefits of participating in the value-based payment models The first step we've included and we have completed is the outreach and the inclusion of the State Employee Health Plan members for attribution to OneCare in 2021 That portion of outreach is complete there is more work to do for other non-participating self-funded groups We also recommended prioritizing increasing the percentage and so here again you see the mirroring recommendations that are focused on bringing more of the overall model implementation into alignment with the performance in our Medicaid program So specifically prioritizing and increasing the percentage of fixed-prospective payment in the VMNG OneCare Vermont contract and we would like to continue to work towards this in requesting that Blue Cross MVP and OneCare identify clear milestones for including fixed-prospective prospective payments in contract model design We've been having some conversations with payers as well as with OneCare Vermont about what this could look like We want to continue with these conversations and to and to lay out those milestones This is an in-progress recommendation and this is a place where I think certainly hearing and working with you and your staff further is something we would appreciate doing This next recommendation is one that is geared towards the Green Mountain care board and perhaps we can have discussion or you can however you'd like to talk about this I am interested in how you might be thinking about this This is certainly something we can be working on with your staff as well So these recommendations recommendations 9 recommendations 10 are specific to the Green Mountain care board in looking at how it is gathering information from OneCare Vermont And so recommendation 10 also asks that the board require that OneCare Vermont identify the chief cost drivers across this network and detail its approaches to curb spending growth and improved quality We have also recommended prioritizing the integration of claims and clinical data in the HIE and we have also organized the HIE so that it is aligned in the office of health care reform within the secretary's office so that we can ideally coordinate and ensure that our HIE activities are driving towards this integration of claims and clinical data We have had discussions about this with the HIE steering committee the HIE steering committee is as well aware of and endorsing the claims integration work that we're beginning with the Medicaid claims data and from there we will accelerate the integration of commercial claims data within the HIE as well This is another key place for collaboration with the Green Mountain care board and staff certainly as you are key users of claims data within the all pair claims database your experience and expertise in this area is very important as we endeavor further with the commercial claims integration and your staff are represented as a part of that process and are participating in the claims pilot We also recommended partnering with one care Vermont as well as delivery system users to evaluate the efficacy of the care navigator platform and this work is in progress We the agency of human services staff have had conversations with and collected information from delivery system users We are also looking at other tools that are available for coordinating care other health information exchange tools available for coordinating care We also know that one care Vermont is also evaluating care navigator as a platform and we expect that along with the other recommendations here in this plan that are directed towards one care Vermont specifically the work that they have been engaged in really seriously since this improvement plan and consistent with the improvement plan their strategic planning process where our understanding is that one care Vermont through stakeholder interviews strategic planning process will be beginning to share the outcomes of their undertaking to really to really answer the recommendations that are directed at them as the ACO that's participating in the all care model so that does include the care navigator evaluation it also includes one care elevation of data as a value added product as well as how one care focuses on its core business as a part of demonstrating value and providing for what we would want to see is additional network participation just moving over to Wendy is there anything you want to add about the care navigator evaluation at this time or I think you can move ahead I'll make a note in the sections I'm doing but okay for now thank you great thank you the next recommendation which is recommendation 14 will condition provider participation and this is a longer term recommendation that in the context of the broader report describes how we could explore conditioning provider participation in the blueprint for health PCMH payments on participation in a value based payment arrangement with an ACO we make this recommendation because it is our an objective as a state to shift more payment to value based payment models when providers are participating in the blueprint for health but are not participating in value based payment models there's a conflict there in what our states overall objectives are again we're going to carefully explore tying PCMH payments to participation in value based payment but you are aware I believe through the ACO budget process you understand that with the Medicare increase that was that was provided through the model agreement that increase that trend increase that we did direct that trend increase could be used for CHT payments for those providers that are at risk in the payment model and are participating with one care of Vermont so we did take a small step towards tying tying additional dollars for blueprint CHT to participation in a value based payment arrangement and specifically because those dollars are originated from the Medicare program tying those dollars to Medicare participation in the model recommendation 15 AHS one care Vermont and community providers should improve collaboration to strengthen integrated primary specialty and community based care models for people with complex medical needs and medical and social needs and to organize VCCI and blueprint for health in the office of the of health reform in the secretary's office VCCI is the Vermont chronic care initiative I'm going to ask Wendy to talk in more detail about this recommendation now thank you I'll note that components of this recommendation are complete while others are still in process so VCCI and the blueprint for health are now organized within the office of health care reform at AHS this is effective as of January 1 2021 so that's been implemented for several months now within AHS we're also approaching this recommendation through a number of lenses really our first activity is to create a comprehensive inventory of available case management and care coordination activities this review is utilizing policy documents to define factors such as eligible populations the scope of focus of those activities the scope of of focus of care coordination components provider qualifications the provider network and payment approaches among various other things we're then going to be pairing this analysis with additional information that we want to collect from the field to understand really how these policies are impacting provider and individual and family experience both of our learnings from these activities will inform our next steps we could do a number of activities such as eliminating barriers created by policy implementing QI or training opportunities or identifying opportunities for improvement through health information exchange so right now we're currently in the first phase of this activity which is the policy analysis phase that I described in the beginning I can move into recommendation 16 that one is AHS One Care Vermont and community provider partners should identify a timeline and milestones for incorporating social determinants of health screening into the standard of care and health and human services settings so here at AHS we are in the early phases of approaching this recommendation like the previous recommendation we're initially performing research on best practices related to social determinants of health screening and examining current policy and activities another activity that is related to this that we're focused on is collaborating with One Care on a grant they received from the Robert Wood Johnson Foundation called the Advancing Integrating Models or AIM grant so through this grant we're seeking to share AHS social determinants of health data with One Care to support risk stratification activities technical and legal or data governance activities are underway to support the activities of this grant and then I just wanted to note in alignment with the Care Navigator recommendation you mentioned before we appreciate that social determinants of health screening and navigation can be well supported through technology and health information exchange so as we're working on other recommendations like the evaluation of Care Navigator we're also thinking about how care management tools and health information exchange can be effective tools and addressing health related social needs and I'm going to pass it back to you for number 17 Thank you Wendy the recommendation number 17 is for the Agency of Human Services through the Blueprint for Health to jointly explore with One Care Vermont and stakeholders the best available tools for capturing real time patient feedback and to pilot such a methodology with willing primary care practices this recommendation has really been made to get at one of the again high level population health improvement goals in this model that we're all familiar with which is to increase access to primary care and by establishing a mechanism to understand more real time how patients in Vermont are experiencing primary care that may give us an important lens into the impact of this model and may also provide for key data points where we can continue improving and continuous improvement is very much a culture that must be fostered for us to be successful in payment and delivery system reform especially as payment and delivery models are long standing multi decades in which the health care system has been organized around fee for service reimbursement this recommendation number 17 is specified as a longer term recommendation and to the end I can say we have not begun yet this process of looking at a real time patient feedback mechanism we want to make some more progress and complete some of those recommendations that are framed as the shorter and medium term recommendations and time frame we also recommended that AHS and the Green Mountain Care Board will prioritize regular stakeholder engagement opportunities these opportunities I see as opportunities both to inform and improve the current model as well as the necessary stakeholder engagement opportunities that will inform a potential future model and potential next agreement these two things certainly do intermix they aren't entirely separate however we will frame different stakeholder engagement activities with respect to these two objectives both to improve in our current model as well as to look forward into informing a potential next agreement to that end and I'll come off of the I'll stop sharing my screen so I can see you now to that end we're looking at a time frame of really launching public engagement in the spring and summertime with the conclusion of a busier time certainly with the legislature in session as well as we hope to see as well the case count in Vermont hopefully start to decline with less of an impact of COVID-19 directly on the partners that are all stakeholders in this model and I know that you referenced that as well in terms of your sustainability work it is a challenge that presents self with stakeholder engagement during this absolutely unprecedented time but it's not one that we think is insurmountable by any means in that process I think it would be very helpful we want to hear from we want to hear from provider, payer health system partner stakeholders about what is working with the all payer model agreement and analysis about what's not working and how that can inform a next agreement we also think it's really important to get that perspective from the regulatory the regulatory body which is you and to be able to have a regular way to engage with you to understand from the regulatory perspective from the duties and requirements assigned to the Green Mountain care board particularly in the agreement what works what doesn't what part of the agreement framework is working what part of the agreement framework can be improved all in service of informing a next potential model agreement. So I assume that's the conclusion of this yes okay so with that I'm going to open it up to board members for comments and questions and so fire away board members I'll start thank you Ena let me turn my camera on I always forget to turn my camera on when I'm talking so I'm very interested in kind of your last statement as to how we move forward and I struggle as a board member as you know and I think some other board members do a bit too in that we can't talk to each other about this stuff without violating open meeting laws and so it's kind of like some child's game where you're hit the pinata or whatever where you can't see clearly so there are some issues today but I do want to talk about I could be totally you know you know on a path that doesn't make sense or but these are things that have kind of you know I've settled on in my mind that are important in terms of moving this forward one would be I'll just lift them and move on one would be that the timeline I think clearly has to accommodate this pandemic it's just been so disruptive you know that we've got to get to a point where the dust has settled and people can clearly lift their heads and look forward but I also worry about reform fatigue so say we have another year to just of the current agreement to accommodate the pandemic and then add another four years on to that and you know I know that one of the early paragraphs of the current model it's described as a test you know that all this infrastructure that we put in place is a test the ACO is a test the risk agreements are a test and to see if this model will work but I think as you get farther down the road to a 8 to 10 year time frame it begins to look more like a bureaucracy kind of establishing itself independent of whether it's successful or not my instinct now is that a one year extension of the current agreement for what it's worth and a two to three year additional time period to land this airplane we do have a lot of the infrastructure in we have the ACO agreement we have value based contracts we have some FPP but certainly not enough and we have a quality infrastructure so all of those important foundational elements you know have matured a little bit they're certainly not mature but they're up and running so that would be one another that I'd like to talk about is FPP and you mentioned that in item number 8 and I'm just finding that important we went through the hospital budget process this year for 2022 and hospitals on average had a 14.5% FPP of their NPR and but in the range was 6% to 23% from the 23% we have a great report down Southern Vermont hospital who I don't know if you saw that digger article maybe a month ago but it was just kind of basically saying that the reform approach is really working down there so but as a regulator I kind of want to know what the goal line is where is the critical critical point where the capitation elements of FPP generate innovation and I don't think it's at 14% or 6% the staff tell me it's maybe starting at 30% 35% but it would just be nice to have that in the model as a goal so that we know what we're working for and it back stops us in the regulatory process another would be the cost shift your favorite topic but I do see the cost shift being kind of a chronic disease of this system that we're talking about for 2021 the Diva folks went into the emergency board and basically said we're not giving any reimbursement increases this year except for those federally mandated and so I worry that let's just make the assumption that the model is working and providers are becoming more efficient that that effort gets undermined and siphoned off through the cost shift and that's a big number I probably had some part in creating it at one point in my life I don't know but to me it's a chronic disease within the system and I hear from providers especially the independent provider that it just sucks the life out of them and so here we are trying to build our core of primary care physicians and they just feel like they're a gerbil on a treadmill it's not moving in a direction that I think can go on and so even some minor kind of approach that said especially with caseloads dropping I mean Dr. Dynastore for example the kid counts in our school system are down 21% over the last 15 years and it looks like the caseload on a lot of the Medicaid programs are at least flatline 21-22 to the data that's on the emergency board and so if folks could come up with a 1 or 2% strategy you know 1% of new money which is 5 million bucks for a percent increase in reimbursement rates according to that section of the law that requires them to report that to the emergency board and a 1% from efficiencies and you know you can always find at least 1% of an efficiency in your systems you can always find it so so something where people when we go to the hospital budget process many hospitals don't even put an increase in for Medicaid I mean it's become such an ingrained assumption that it's zero year to year and I just think that that is wrong and finally an issue that I think we've discussed before is this benchmark plan it's very clear that the benchmark plan needed the all pair model and that there is not a tight alignment with the population health goals in the all pair model and how the benchmark plan is structured but I worry that we and my fellow board members warned me of this and I see it unfolding is that we open up the benchmark plan and it just becomes a grab bad for additional benefits and there's a bill in the House that's doing just that it says you know it's basically putting the cost of this new benefit onto premiums and onto Medicaid or onto the Medicaid cost shift and I just I just think that you know that that timing on that isn't right is that we could just we should simply align the benchmark plan with the all pair model goals for example pre diabetes you know there is no organized focus in the benchmark plan for pre diabetes but we have a great plan you know in terms of blueprint working and you know so they have a program that is totally independent of the benchmark plan so that alignments important but if it's just going to be a way to again taking the efficiencies that might be found in the benchmark plan and using them to in a way that's inconsistent with with the goals of the all pair model which include capitation and the reforms that come from that then it just seems like we're shooting ourselves in the foot so those are kind of the areas that that roll around in my mind and helpful not I thought I'd put them on the table thanks thank you Tom other board members I'm happy to go next or thank you Hi Ena and Wendy nice to see you thank you for joining us and giving us an update I did have a couple of questions related to the improvement plan first of all Wendy your your discussion around some of the care management inventory stuff I just wanted to make sure that you are aware that there's been a ton of work done in the sim program and so I'm hopeful that some of that work you'll be able to build off of and that you won't have to recreate the wheel so just wanted to mention that just in case so that's good and I'm interested to I'll be interested to hear what comes out of the care navigator conversation we did include in our ACO budget order we have an update with our staff in terms of demos on the tools which was how we looked at them in the initial certification process so I think it'll be interesting to see your analysis as well because that's certainly something that we look at in certification and budget hold on just one second I'm just looking back at the plan to remind myself what else I had for questions in terms of I just wanted to talk a little bit about the fixed perspective payments so I think speaking for myself I do think looking at ways to move forward on fixed perspective payments in the Medicare program in a different way than they're currently structured makes sense and so you know I don't think we as a board have we talked about fixed perspective payments and certainly emphasized how that appears to be a payment model that allows for greater delivery system change momentum but I for one would love to see at the staff level some work with our folks in your folks moving forward on developing what that might look like there are I think different issues with Medicare than with Medicaid and so I'm not sure if an exact mirror makes sense I really need to understand as you both probably know I'm a detail person so I like to understand the nuances so but it seems to me that if we if the parties to the all pair model agreement agree that that's an area that we want to explore that perhaps at the staff level that could get going because certainly December is right around the corner so that was something I wanted to throw out both for you guys but also for my fellow members in terms of having that discussion because I think that there could be some fruit there and then in the commercial sector I think as you know included in the provider reimbursement report options that we included that we were asked to do by the legislature we did include some regulatory options which could further moving towards fixed perspective payments in the commercial sector now those are regulatory they're not provider led or voluntary type models because it is a regulatory system by its nature but I just wanted to mention that because I think there are there are your recommendation which makes sense given the current authority at least that we have that this be a conversation makes sense to me and certainly moving away from a provider led model is a big shift so I'm not suggesting that we're ready for that I'm just indicating that I think that there's different ways to look at that and I think that certainly as you may or may not know we routinely ask in both rate review and hospital budgets about the commercial sector and get updates on the Blue Cross pilot with Southwestern on how that's going so that's another area of interest to me as well those are the things at top of mind I'll look back through my notes while other folks talk and let you know if I have anything else thanks. Thank you Robin other members of the board yeah hi Ena hi Wendy it just wanted to first of all just thank you again for the updates and it sounds like some important progress has been made which is impressive given all of the other distractions and other important issues that we're trying to deal with with covid so it's good to see some of that progress and I appreciated your remarks at the end about the process going forward with as we think about a possible next agreement with the federal government having some stakeholder engagement and having an opportunity for regulators to weigh in we certainly have a different perspective than maybe other stakeholders might we see things you know through our lens and it would be helpful to be able to have that conversation this summer at some point if it sounds like that's when it might be I wanted to just ask you a little bit more about and maybe this is a little bit of building on Robin's question around or interest in the self-funded and commercial plans and their the obstacles to fixed payment that you might have uncovered in some of your conversations or your learnings just wondering if there's anything more you might be able to share or dig deeper into that with us a little bit as we're heading into rate review season and other types of our own regulatory process are there any learnings that you have that you could share with us that might inform our conversations going forward I think as you and your staff are familiar and we've worked together on this in the past that when there are plans that are not directly regulated by such as self-funded plans that aren't subject to the same types of state regulation that a fully insured plan is subject to then the tools for garnering that participation are more limited right there isn't that regulatory approach that Robin just referenced that could potentially be in place for that fully funded commercial plan so that remains a barrier I think one of the aims and the implementation improvement plan is to do education and outreach to those self-funded groups that are not participating at this time and as I mentioned we've managed that with the state employee plan we still have more work to do in terms of communication and outreach and I think that that's the immediate tool. I do think that it's another important conversation that we can convene perhaps with our partners at the Department of Financial Regulation to understand better the totality of potential influence that there could be at the same time acknowledging what Robin's comments as well or Board Member Lunge's comments as well that that is maybe not something we're fully ready for moving from voluntary to mandatory and I think that that's going to be a conversation that comes up a lot as we look at what works and what doesn't work in this current agreement and how we approach the next and that's one that I think we'll have to have in forums like this and in other forums as well I also wanted to say as we continue these conversations you also have key data and information that can inform the conversation like the information that Elena was presenting earlier prior in this meeting I think that there the information that will become available regarding the sustainability planning and what your consultant is gathering from the field could be very informative too as we think about what's working what's not working and how to look at a future potential agreement sounds good thank you okay other members of the board yeah first thank you for the presentation and all the work you've been doing behind this when you look at the APM improvement activities that are still open which one's concerned are there specific ones that you're concerned about as far as progress or timing or are you getting cooperation from all the partners I don't know that it's necessarily concerned but the area of significant focus is in that prospective payment model modeling and working with CMMI in how we approach that I want to have conversations with them too about that and what that looks like again board member one raises a good point that there might be some differences in how that looks for Medicare while we have expertise from our Medicaid program in providing and running this payment model I think those are learning that we can share directly with our partners at CMMI so that they can then respond based on their experience with the Medicare program their ability to potentially put in place alternative models to the current Medicare payment model which does include that reconciliation component that is ultimately reinforcing some of those fee-for-service incentives okay good thank you that's all I had okay does anyone else from the board have anything further before I turn it over to the public for public comment Kevin I thought I'd just jump back in on 9 and 10 which were the recommendations to us before I do that I think like on the FPP I do think we should have a better idea of what we as a state is the want as the right direction not that we shouldn't share our information our you know what we feel like we've learned with CMS around Medicaid but I do think it's important prior to going into a negotiation to have kind of that state perspective clearly before we start accidentally negotiating against ourselves so that would just be my two cents on kind of trying to move forward with that analysis sooner than later on 9 and 10 so I'm going to start with 10 which is the ACO cost growth drivers which is something that I think we have been working on in the ACO program for a couple of years now so we did include in our 2021 reporting manual these sorts of information and also in 2020 we got some reporting so I do think that we I'll just speak for myself I guess I think that we are interested in getting a clearer sense of connecting all those dots from the provider level through the ACO and payer level in terms of the using the ACO and hospital budget process to look at ACO participants moving towards their different sorts of physician compensation I I we did actually hear a little bit about that in the hospital budget process a few years ago of course last year and this year we're doing a much more streamlined process because of covid and so certainly you had listed as a longer term suggestion and certainly like this is not the year for us to be doing that but I think we do we certainly don't have the ability to do a contractual kind of review but in terms of our staff resourcing but for me I think it would be I would be interested in hearing more from hospitals in the longer term future about how they're thinking about connecting all of the dots on their end and I I don't know that we have really to me it might be a step too far to be putting requirements but again this is a longer term thought process so that's just my thoughts on nine and ten thank you Robin anything further from the board if not is there members of the public who wish to offer public comment I saw a hand go up Ham Davis I've got a couple of questions can you hear me okay Kevin we can we get a great shot of your computer the Dell it's a fancy computer one of the most interesting developments in the last few weeks here has been announcement that they're going to go into business with MVP to deliver to offer starting in the fall offer a Medicare advantage plan question the first one I'd like to ask is my understanding is that that you cannot that people in a Medicare advantage plan can't be attributed to the ACO is that true no I don't think that that is categorically true I think that an ACO can could work with a Medicare advantage plan and could enter into an arrangement that would be a qualifying scale target initiative within the current agreement framework well thank you I'm not so is it conventional is it a conventional attribution in the way that we do it now or is it something different I mean right now what we have is we have what happened primary to take his patients and attribute those patients to the ACO is that right is that how we get attributed I think you said primary care yeah for we have a model in the northeast that looked at using using a as a pilot using using hot connect it's bypassing the primary care but that's just the pilot the rest of the people that are attributed to one care Vermont as we speak I believe have all been put there by their primary care physician is that wrong the primary care primary care providers participation in the ACO yes is the factor that attributes many of the attributed lives well I mean who would do the rest it's not all many not all is there some other way active in this state now to attribute people to one care yes the medicaid program does have an alternative attribution methodology that is not based on an individual's primary care provider when that individual does not have a does not have a primary care provider established and thank you the other question I always not not a fat question the one of the from the last several years one of the major questions on scale and on the question of how well the whole system works at the really where the rubber hits the road which is whether we when we stop to save money on prospect of the payment systems the question has been we have medicaid in there we have we don't have Medicare in there and we and we have had very little little or none actual prospect fixed payment contracts what is you what do you what is the state administration believe how do you assess the the potential effect of the uvm it managed the you know the Medicare Advantage plan we have an assessment of that plan at this time as I said I think there is a potential that the plan would collaborate with an ACO in order to provide population health management that would allow the plan to work work and perform better within its cost targets but but I said that's as much as I can say at this time thank you okay more Wasserman thanks so the mute buttons off first I was very gratified to see mention in the implementation improvement plan of social determinants of health but I was a little puzzled about the emphasis on screening for it so I wanted to ask in a back and when the trapped and about how the agency of human services which is sitting on incredible amounts of data about social determinants of health whether it's department of children and families for childcare assistance or corrections housing needs medical transportation information about substance abuse information about disabilities what the agency itself is doing to integrate those data and pass them on to community agencies or healthcare providers we are focused on integrating those data in a stepwise process into that health information exchange we are prioritizing first integrating claims and clinical data in the health information exchange next focusing on what we believe because of changes at the federal level we will be able to incorporate mental health and substance use disorder data into the health information exchange and then from and then the next area of focus is to include social determinants of health data in the health information exchange those data being the ones in part that you named that are existing now within the agency of human services the focus on the screening for social determinants of health is one wherein we are promoting that within patient center and medical home setting that those social determinants of health are being potentially identified if there are barriers to health and well-being that are social determinants that those be identified but I think it's really important to say that we want to pair that recommendation with the work that we are beginning with our blueprint for health team as well as our chronic care initiative team as well as working with the broader agency of human services and the programs and services existing there that are available to address the social determinants of health when there is an identified need and so the idea being to bridge the medical and social services care continuum not just building a bridge for the sake of building a bridge but ensuring that once you cross that bridge that system to address the social determinants of health is as strong, integrated and well-functioning as it can be. Thank you. Next I'm going to go to Dale Hackett Dale? Inna could you just clarify when you were talking about the attribution of life if you're in Medicare if you are a dual and you're Medicaid and Medicare could you include that as well because that often gets left out as far as a population Thanks. Dale if you are an individual who is duly eligible for the Medicaid and Medicare programs and your primary care provider is participating with One Care Vermont you will be attributed to One Care Vermont as a Medicare beneficiary. Okay. Other public comment or questions? Hearing none. One final question, Inna. How do you and Wendy feel that this is going and are there concerns areas that concern you that you don't think are moving as fast as you had hoped? Again, I'm not going to go as so far as to say concerned but I am also very anxious for the time where we can know that our federal partners have settled down in their leadership and in their new within their new administration and that we can really get to the table with them to be having some conversations about what we propose specifically in this implementation improvement plan. So it's not a concern but it is a place where I know I'd like to get to more quickly and but I also would fully expect the transition time. We would anticipate that during the transition time that there's a little bit of a change in our partnership and important and as we all know that the global health pandemic does create some additional drag on transition times because there's so much effort that's happening to try to address the immediacy of the public health emergency. But I'm not concerned at this time. I'm just a little anxious and excited. I think we all have that anxiety. So with that I wish to thank you and Wendy for a great update on the implementation plan and we look forward to working with you to try to be as successful as we possibly can be. So thank you both for your efforts on behalf of the state. With that is there any old business to come before the board? Kevin I just have one thing I wanted to mention about a brief update on the prescription drug tag which I know has a scheduled meeting on Monday. So the group decided at its last meeting that we're going to shift to and by we I actually mean the group members not me are going to shift to a subgroup structure to try and focus and accelerate some of the policy development work which is proving challenging in trying to do that with a big group. So we may end up canceling Monday's meeting it looks like members want to just jump right into their subgroups and start cranking through the work. So I just thought I would mention that to the board that that's a shift we'll still have monthly meetings of the full group to get reports in from the subgroups and as soon as proposals are ready to fully vet them through that larger group. But I think that may help us move forward a little bit more quickly. That's great Robin. Thank you. Okay Thank you. I know that this is a very old business to come before the board. Is there any new business to come before the board hearing none would someone wish to make a motion to adjourn? So moved. Second. It's been moved by Robin and seconded by Tom to adjourn. All those in favor of the motion signify by saying aye. Aye. Those opposed signify by saying nay. Bye bye.