 Good afternoon and welcome to the Green Mountain Care Board. My name is Kevin Mullin, Chair of the Board, and I'm going to call this meeting to order. The first item on the agenda is the executive board, Susan Barrett. Thank you, Mr. Chair, a few brief announcements. As a reminder, we are accepting public comment on OneCare Vermont's ACO FY22 budget and 2022 certification until this Friday, December 17th. Close of business in order to be considered ahead of a potential Green Mountain Care Board vote, which is tentatively scheduled for next Wednesday, December 22nd. And also an ongoing public comment that we've had up since February of this year, and that is for anyone interested in sharing any public comment on a next potential agreement with CMI Mine, CMS for a future all-pyramidal agreement. Any of those comments up to date we, and in the future, we will share with our colleagues at AHS and at the governor's office as they will be leading the negotiations. And then a scheduling reminder this evening, we will be having the primary care advisory group meeting which starts at 5 p.m., and that's via Teams. VMS will be presenting their primary care platform for prioritization. And that's a lot of alliteration. It's a nice name there. So that should be interesting. Those materials are on our website as well under the primary care advisory group. And then next week, we have a potential vote scheduled for one care of Vermont's budget, as I mentioned earlier. We also have a potential vote schedule for the Medicare benchmark proposal for 2022, which you'll hear about today. And then we also have a potential vote on the calendar for the all-pyramidal agreement proposal to request one-year extension that's also on our calendar today. So if we don't get to it today, we have that noticed for next week. And at this point, we don't have any time scheduled for the 29th, but that is listed as TBB. So I will turn it back to you, Mr. Chair. Thank you, Susan. Next item on the agenda are the minutes of Wednesday, December 8th. Is there a motion? So moved. Second. It's been moved and seconded to approve the minutes of Wednesday, December 8th without any additions, deletions, or corrections. Is there any further discussion? And Michelle, Degree, if I could just ask you to mute the line, we're getting feedback. Okay. Any further discussion on the minutes of Wednesday, December 8th? If not, all those in favor of the motion, please signify by saying aye. Aye. Any opposed, signify by saying nay. Let the record show that the minutes were approved unanimously. Next up on the agenda is the 2022 Medicare benchmark proposal, and at this point, I'll turn the meeting over to Sarah Lindberg. Good afternoon, board. My name is Sarah Lindberg. I head up the data team here for the Green Mountain Care Board, and I am here to talk about the Medicare benchmark. Most importantly, is everyone able to see my screen? We can. All right, fantastic. So please let me know if I'm starting to go too quickly, as always, but I just wanna start off by saying that this year's as tricky as it has been for the last couple. So I'll do my best to make it as a little clearer than mud. So we're gonna start by just reminding ourselves what's up with these benchmarks, talking about the background, what the experience has been to date, and then go into what I'm recommending for the 22 benchmarks. So always good to keep in mind that there are multiple agreements in place underneath this big all-payer model umbrella. So the Vermont All-Player ACO Agreement, which I usually will call the agreement, is the one between CMS, the Medicare agency, and the state of Vermont. And so the signatories for the state of Vermont include the Green Mountain Care Board, the Agency of Human Services, and the Governor's Office. Now completely separately, but entirely related are the contracts the ACO has, both with payers for the target setting, like we're talking about today, and with the providers, who are the ones who are actually providing care and attributing patients to the model. So the agreement that the state has with CMS gives the GMCB the authority, including some duties in setting the financial targets in the contract between the ACO and Medicare, known as the participation agreement. Always need to remind ourselves that what we do is we propose targets, and then CMS has the option to either approve those targets or can request their modification. Unfortunately, there aren't any standards listed by which they make that assessment. So that is under their discretion. Another confusing piece of this puzzle is that for Medicare purposes, the all-inclusive population-based payment, or AIPBP, is calculated and reconciled completely independently from these financial benchmarks. The AIPBP for Medicare is designed to provide a stable funds flow to providers, that we do our best to get it right, but that's based on the amount of care expected to be delivered to attributed beneficiaries by participating providers who opt for that payment arrangement. However, for the ACO's purposes, their total cost of care comprises the fee-for-service payments made like the old days, so people who aren't participating in AIPBP, so that might be out of state, that might be in-state providers who don't do that payment arrangement, plus what would have been paid under fee-for-service that are associated with these AIPBP claims. So if you want to look at how it's sugared out so far in 2021, the solid line are the fee-for-service equivalents. Those would have been paid amounts that the ACO population has incurred, and the dashed line is those AIPBP payments. So most months, the fee-for-service equivalents have been under that. There's been a few months that we've gone over, which is unusual, especially that time of year, which is a little indicator of how wonky 2021 has been. But at the end of the day, this will be a completely separate reconciliation. This is really another positive issue. So the benchmark, as we're gonna talk about it today, really has three major components. There's the historical experience. So that's what we think the per member per month, or PMPM will be for 2021, based on who's participating in 2022. So it's not the actual 2021 population. It's who would have attributed last year if the 22 ACO network was in place. We also multiply that by the number of people who will be attributed in the upcoming year. And today is the GMCB's decision and how we trend that. So that is what do we think a reasonable target and growth rate is from 2021 to 2022. And that's how we get to our benchmark. And in Medicare, one of the ways that we help with mitigating some of the risk is that there are actually two benchmarks. One is for folks beneficiaries who are eligible for Medicare due to end stage renal disease or ESRD, and then the rest of the population. So there aren't a whole lot of beneficiaries in the model who qualify this way. However, they are substantially more expensive. So having them have a separate target and reconciliation process provides a little protection to people participating in this model. And so the agreement has certain duties assigned to the Green Mountain Care Board in setting these targets. And one of the criteria in those duties is that the trend be set at least 0.2 percentage points lower than the national projections released for the Medicare fee for service population nationally each year. So normally that letter would come out in April. So for 2022, we would have normally expected the letter to come in in April of 2021. However, the real kind of intent for these projections is for people who are trying to set targets and premiums for their Medicare Advantage business and due to all the uncertainty, there was real pressure to get these estimates out as soon as possible. And so the letter was actually released in January of 2022. So that might introduce a little bit even more uncertainty into these projections than there normally is. So that's just something to keep in mind. You know, guessing 2021 today is not clear to me. So guessing it back in January would have been even fuzzier. So just want to keep in mind that these projections have a ton of uncertainty more than ever before. So do you expect them to return to April this coming year or do you think it will be another year of an early release? I have not heard any leaning one way or the other but my hunch is it'd be more like April. I think people are interested in more information at this point, but hard-telling not knowing. So these have been the trend limits to date. So because nothing is ever simple with this model and agreement in 2018, there was a special provision that said if the growth rate was in a certain range that the Green Mountain Care Board would have the option to use something called the floor which was using a growth target of 3.5%. So that was the limit of the growth in 2018 due to the observed growth from 2017 to 2018 which was actually more like 2.7%. The limits in 2019 were 3.8% and 3.1%. Again, prospective limits for 2020 were 4.0 and 2.9. We know that that's not the way 2021 at all. And then, so again, those January estimates for growth for 2021 were 4.4 and 2.3. Those are turning out to look pretty darn low in my estimation. And then in 2022, they're projecting really high growth. So they're projecting a 10.4% growth rate for non-ESRD and a 7.6% for ESRD. Now, everywhere I've looked indicates that these are probably pretty high estimates. But again, they were doing the best they could back in January for almost two years later. At the end of the day, the Green Mountain Care Board needs to keep its Medicare growth under a compounding annual growth rate from 2017 to 2022. That's as it's written today, no factoring in for the extension yet, which means our target would be 5.2% for the non-ESRD population and 3.9% for the ESRD. We have no risk of coming close to those. The 2020 has done a number. So I'm not stressing about that, but I wouldn't recommend that coming into your thoughts about this. So what has the board decided so far? So in 2018, as I already mentioned, the board chose to use that floor provision in the agreement. So the trend rate was 3.5%. In 2019, the board chose to use the maximum allowable trend rates, which was 3.8 for the non-ESRD population and 3.1 for the ESRD benchmark. And in 2020, we ended up revising our proposal and reverted to a retrospective trend just to see, due to all the uncertainty, we weren't sure where things were gonna sugar out. And so that observed trend rate from 2019 to 2020 was minus 7.7% for the non-ESRD population and minus 2.2% for the ESRD population. We won't be able to calculate the 2021 growth rate until we have full run out, but we do expect that to be likely a double digit growth rate for both populate. Well, I'm sorry, for the ESRD population, ESRD has been a lot more stable, which makes sense. Their care is gonna be a lot less sensitive to the pandemic. There's a lot of care they need no matter what. So what do you do with a problem like 2020? I wish I could solve that in a musical, but unfortunately, there's no good answers here. So what we do know is that 2020 is kind of garbage in terms of target setting, it's meaningless. There's not really a lot to gather there because for obvious reasons. And so as a result of that, a lot of programs are choosing to base their 22 rates on 2019 claims. So that also introduces additional uncertainty. You still have to trend it somehow. However, you're at least starting from a base that makes some sense to people. However, CMS had a strong preference that we impute the 2020 experience for our modeling, which means that instead of relying on what actually happened to the reference population, which is the dark solid line, they said, well, if we were basing this on traditional Medicare claims, what would their experience look like? And so that gets the dashed line. So any modeling that was done by CMS involved that imputed information. So that means that 2020 doesn't go down in the model. It just looks like any old year when we stick it into our modeling. So again, a lot of uncertainty is still to be unfolded. But if we look at our all payer total cost of care, which is what the range of 3.5 to 4.3% growth, the model is centered around achieving. I would say that based on what I know, we still have to finalize the repricing for 2020 for our Medicaid hold harmless provision. But I would say that we're probably looking at a range of $500 to $510 per member per month. So obviously quite a dip from the 542 at the end of 2019. And then 2021 is really a mystery. So there's a big gap in where that might land, but despite all that uncertainty, we are pretty confident we've got quite a margin for the all payer target. So I would say that from 2021 to 2022, our kind of headroom is between 5.5 and 16.7%. That's a huge range. It's the best I can do. There's a lot of people making great guesses out there, but if they have a narrower range, I don't know that I would trust it anymore. This is an honest assessment of the uncertainty in my opinion. And so if we look at how Medicare has grown over time, the bottom line here, the solid one, that's the dark blue is what Vermont's actuals have been coming in at. And the solid line, the furthest north is the US actual. And I just, I always want to just mention that Vermont is an incredibly efficient state for its Medicare population. Like these are incredibly, you know, I think we don't get enough credit for like these numbers. Like I think that they're impressive. So I just always want to make sure that we keep that in mind because growth rates can mask that really important point. And splitting the difference there in the dashed lines are, so the projections, like I said, are released every year. So this is what the historical trend and projections have looked like according to the 2022 announcement. So as you can see, everyone takes their nosedive in 2020. You will also notice that Vermont took a more substantial nosedive than US. I believe that that's almost entirely due to the fact that we did not have a lot of expenditures related to COVID. So we deferred more care and had less treatment expenses than was observed nationally. You know, there's other reasons for that as well. We, you know, we often have snow birds. So this would include care that was potentially delivered out of state in Florida. I think that was less true in 2020. So there's a lot of things to unpack, but relatively speaking, Vermont's decrease was greater in 2020. So again, you know, it's always hard to think about trends and growth rates for me, but here we have what the growth rate has been for that Vermont actual, the dark blue solid line, the light blue solid line is the actual growth rates for the US population annually and then the projected growth rates. So right now we see that there is projected a pretty huge increase for 2021. That's about probably what we're gonna be expecting this year, but they are also expecting a pretty substantial growth rate in 2022. That's that 10.6%. And then they have it kind of calming down after that a little bit into more historic ranges. So when it comes to being attributed to the ACO for the Medicare program, we have to remember that we've got some bias and who's gonna be attributed. So they seek care. They've got primary care claims. So they tend to be a more expensive utilizer type population, excuse me. And we're also gonna be limited to the types of providers that participate in this model. So we kind of have it from both sides. So for instance, if people are a majority of their primary care relationship is with Dartmouth Hitchcock in Medicare, we're not mist picking up those lives today. So the top dash line is what we call the prospective alignment. This is what we measure for scale purposes. So that's when we apply the attribution algorithm to the claims for two years prior to the upcoming performance year. That's how many people would attribute to the model. And then at settlement, we see who maintained their eligibility for either the full performance year or up to the point at which they passed away. And so that's why you see a drop between who's included for settlement purposes and who is prospectively aligned. Now those lines have very different trends in 18 and 19 than the relationship in 20 between the two. And that is 100% due to the Medicare Advantage penetration rate. So we expect that 2021 will probably be, the latest assessment I saw was probably gonna be closer to 42,000. And we seem to be losing more lives every month due to people taking up that plan. And then also similarly, 2022 is likely to continue that trend where as more and more people sign up for those options in the state. But these are factoring in the known exclusions to date. And that is one change we made for the benchmark today is that usually we would put the 62,711 in the benchmark but we said that's just not true. We already know we're down to almost 52,000. So we're gonna use the number we know so far. So one cares results to date. So these are each of the first three performance years. So the bottom bucket are the fee for service claims. The top bucket are those that were paid through AIPBP. So that is the fee for service equivalents for services that were actually delivered. And anything that was different from what was prospectively paid was reconciled elsewhere. So the dashed red lines show what their target was and you can see that in 2018, the ACO was about $14 million below the target. And this is just for performance. There's other things that happen at settlement. In 2019, they were $2.4 million above their target. And in 2020, the spending ended up being $27 million below the target. Obviously 2020 really isn't about performance so much as it is just a crazy pandemic year. So that one is what it is, but I think it's always important to separate out the performance targets from the rest of it. So when it comes to actual settlement, this is why I was saying it's a little bit of a different picture. So the top line here is showing what the gross savings or losses were for the ACO. That includes the advanced payments that were made to fund the blueprint and SASH programs. So below that is what the cap is on the gross savings and losses and the cap is a proportion of the benchmark. So in 2018, it was a 5% corridor. In 2019, it was a 5% corridor with 80% risk sharing within that corridor. So this is just the total corridor. So that's the cap. So when we apply the cap, you're either gonna have the lesser of either the gross savings or the cap on the savings. So the cap really has only come into play so far in 2020, which makes sense. Then there is quality adjustment. 2018 and 2020 were really paying for measures. So there really wasn't a meaningful adjustment. So 2019 was the only year that we actually applied any sort of quality adjustment. And then again, that ACO risk arrangement is the risk inside the corridor. So once we adjust for that, the gross final savings in 2018 was 14 million. It was 11.3 million in 2019 and 16.3 million in 2020. However, part of those savings were advanced. Again, to help with cash flow to fund the blueprint for health and SASH. So when you factor that into the equation, the ultimate check to the ACO is emboldened in the last line there. So ranging from 4.9 to 7.9 million over time. Now, this is again, a completely different exercise from reconciling the AIPBP. This is just based on the risk and the financial targets. So that's a different equation that's not factored in here. So I can't overstate the amount of uncertainty there is right now between hospitals being full, the intensity and number of services that are being produced. And then at the same time, the focus on necessary care and additional deferral of elective services, which is always a controversial thing to think about. But right now our estimates for key for 861, I, if I were a betting man, which I'm not, I'd say that's gonna go up. And I would have seen estimates ranging from a PMPM of 8.15 to 8.60 for 2021. So that's just an incredible amount of uncertainty to have this time of year. Usually we feel a lot more confident about where it's gonna land. So, you know, that's not really a trend decision. I just wanna be clear. That's like an experience estimate that we can get right. We can fix that and see where 2021 actually lands. But I just wanna be clear that that's a known unknown as I will talk about in a minute here. So again, that experience for 2021, the base might be wrong. So we are going to run numbers after we have three months of run out for the calendar year. So that'll be around April of next year. And if it's wrong, we're gonna update it. So if we've got it wrong, we will totally update that and make sure that we're starting from a fair place. Another known risk is that if the public health emergency on the federal level were to expire, that might take with it some of the flexibilities that are currently allowed in the ACO program. Most notably right now, expenses associated with COVID-19 episodes are removed from the ACO's total cost of care. So if those were to come back in to the ACO's accountability, we would need to adjust the benchmarks to make sure that we either account for that in the experience, add those expenses back into the experience or adjust the trend if we think that expenses associated with treatment are not comparable to the baseline period. So that's something we're monitoring closely. Similarly, there is a very expensive Alzheimer's drug. I won't try and embarrass myself and to pronounce it. However, so they are gonna take up whether or not they will cover that starting in April of this coming year. If that were approved by Medicare, which is definitely not a given, given some of the controversy around it, we would definitely make sure that that was accounted for and that the ACO would not be accountable for expenses that they are not in their base at all. But that's probably unlikely to fold out in 2022, we're hoping, but we will cross that bridge. And these are the ones that are kind of keeping me upnights in terms of setting the trend and that is, so the Medicare Advantage penetration rate we expect to increase again in January. And if what we have seen to date continues, that might just really change fundamentally the population left in traditional Medicare. And so if that happens, we're gonna have to address it. Also with our capacity at maximum, people are having to make referrals that they wouldn't otherwise. And those are, in my judgment, unavoidable expenses that we need to account for if that ends up being a problem in 2022. The deferred care, that's a tough one because foregone care and deferred care so far have kind of been netting out in all the actuarial modeling I've seen, but we have to keep an eye on it and it just might still be coming. So if it seems like, especially the intensity of the care is increasing and increasing the expenses, we will need to make an adjustment for that. And then of course, COVID-19 is a very difficult thing to predict. So if there are either immediate or related effects that are affecting the trend, we will need to adjust it as well. So I think at the end of the day, what we need to do is make sure we're monitoring 2022 closely. And if any of these things suggest that our revision of the trend is required are necessary that we would do that with the, in consultation with CMS, I think we can make a proposal at any point, but we're pretty good at partnering and making sure to keep things as reasonable as possible from our agreement standpoint. So when I was looking at the problem of what's gonna happen from 2021 to 2022, I was trying to imagine who's gonna have the best most recent information about what's gonna happen in 2022. And that led me to review the Medicare premium announcements. So every year in the federal register, they announce how the premiums for both part A and part B are going to be projected to increase for the coming year. They release them in November, which is about as late in the year as you can get a gas for Medicare about the next year. And what I did is I blended together part A and part B, and then part B actually has components for the disabled and non-disabled populations. And when I do that, it's been pretty in line with the other Medicare Advantage announcements and tracking pretty closely with what we're seeing in Vermont. So for instance, if you look at the experience from 2018 to 2019, Vermont actually grew at 4.1% and the US at 4.1%. The call letter had expected a 4% growth and the Medicare premiums were expected to grow by 4.4. So that looks pretty good to me. 2020, we can't blame anybody about it. That was ahead of time. It was a totally reasonable guess at the time. But where it's interesting to me is in the growth from 20 to 21, that's where the call letter... So again, this would be the call letter from April of 2020 for growth to 2021. They only showed a growth rate of 4.5%. And I believe that's because they expected some of the care to start coming back in 2020. So again, they have to release theirs substantially earlier. So that one to me just seems wrong whereas the Medicare premiums look a lot more reasonable, 9.2% growth. And so I think that's part of what's going on in this discrepancy between their projections for 2022 because if you net out the growth for this whole time period, they both end up in about the same place. So I think that essentially the call letter got it wrong in 2021 and some of that's making up in 2022. But that said, it's a guessing game. And no one knows what's gonna happen in 2021 which is why the monitoring is essential. So I just wanted to show you kind of the menu available to the board. So the left hand rows are showing you kind of the range of potential experience estimates for 2021. That's not anything for you to decide on. That's just like kind of giving you some context for how these things would sugar out depending on the experience, just for kind of reference. The Green Mountain Care Boards decision is really across the column. So using a 3.5% trend, which is the floor of growth according to the agreement. According to our current estimate of experience, the target for the ACO would be $856 per person per month with a risk corridor of $10.9 million. And I would say, please don't go anywhere below that. That would be nuts. So that would what I would call the floor of a potential decision. And the ceiling again is according to the agreement and according to the letter that would bring the per member per month target up to $913 and bring the risk corridor up by 11.9 million or I'm sorry, bring it up by 1 million to a plus or minus 11.9 million. So you'll notice that these numbers, despite big changes in trend, aren't changing the risk a lot. And that's because of a 2% corridor. So the risk corridor is really gonna constrain this quite a bit. And so my recommendation in the middle is a 5.5% trend and that's based on that Medicare premium that I explained. And that would result in a PMPM of 873 with a risk corridor of 11.1 million dollars. So, but I mean, I think with the risk corridor as tight as it is, there's not a lot that's gonna happen for that ultimate plus or minus for the ACO. The target needs to be adequate and fair. And I think anyone's guess is as good as mine for where that might actually end up. But given what I know today, I would recommend a 5.5% trend for both the non ESRD and ESRD changes, but certainly in our proposal to CMS make sure that these guardrails are in place. And that is that we monitor both the 2021 experience and make sure that stays accurate and keep our tabs on what's happening in 2022. And that if there are material changes to either benefits or protections in place during the performance year that those are reflected somehow on the benchmark. That said, if everything goes off the rails again and we're back in 2020 kind of uncertainty levels, like I would advise that we propose a retrospective trend and both CMS and the ACO understand that that is completely on the table and that despite our best efforts, it's just a very tough sledding out there when it comes to trying to predict anything. All right, so that's the trend. So this other little tack on is related to advancing the shared savings. So as a reminder, Vermont has a pretty well-regarded program known as the Blue Print for Health and that includes payments associated with primary care medical homes, community health teams. And peripherally, we have some investments in support and services at home or SASH. And that funding for Medicare stopped in 2016 when the MAPCP demonstration ended. So the all-payer model included some provisions to continue that funding by Medicare. So one of the only ways to get the money to the state is to put it in the benchmark. And the way that it works mathematically is it's not really performance risk, it's just tacked on, but it is reconciled at settlement. So mathematically, what you're deciding on is that first kind of equation in Perenn, specifically the trend. So that gets all figured out and then at the very end, they add on the shared savings. So the performance risk is separated from this blueprint stuff. And so my concern is that using a 2% corridor is again gonna constrain the total amount of shared savings possible. So given the increasing Medicare Advantage penetration, it's possible that the people left at the time of settlement might so severely constrain the savings that there's a scenario where the ACO would not even be able to earn back that advanced savings. This is an uncomfortable position for everyone. And that is one of the main reasons that we are looking for alternatives, ways to fund this next year and beyond. So if I have any power in this, this will be the last year that we're faced with this unfortunate kind of arrangement. But just for, I do better with pictures sometimes. So the line going across is that advance of the 9.1 million that you may order the ACO to invest in those programs. So if you look at a 2% risk corridor, the margins are very narrow. So the darker, taller bars are kind of what the risk corridor looks initially. The lighter, green, shorter bars are what we would estimate at settlement. This is based on basically a 25% attrition rate, which is what we saw for the reference population for the current benchmark. I would guess it's probably gonna go down even lower, so those margins are gonna get thinner. So I just think that that's a real risk that might occur and something to monitor if the ACO does elect a 2% corridor, which these risk, these maximum potential savings are also maximum potential losses. So I know it's an uncomfortable time to think about taking on additional risk, but I do think if there were appetite, to increase the corridor by half a percent, that would give them a lot more breathing room for avoiding that possibility, but that's 100% their decision. The Green Mountain Care Boards decision is at the bottom and that is those risk corridors, I'm sorry, those trend rates for the benchmark. But again, you'll notice that those trend rates are moving the bars much less than the risk corridor. So the risk corridor is just a lot more powerful way to influence this than the trend rate. And it's really a separate issue, but I just wanted to kind of demonstrate what I'm talking about. So I would recommend per the preference of the ACO that the full amount that you order be advanced in the Medicare benchmark, which I think I got my math right, and that you would continue to use those to support the state programs. I'm sure you're sick of hearing me talk by now. So what questions can I answer? So questions for Sarah? I have a couple of questions. Could we go back to slide 12? It's echoing quite a bit, I'm not sure why. Yeah. Maybe it's just on mine. Nope, I could hear the echo too, but it's better now. Yeah. So Sarah, I just wondered if you could, and maybe I missed this when you were talking. So my apologies if you said this, but could you talk a little bit more about which, I know this isn't our decision, but I'd like to understand a little bit more which programs are using the 2019 claims. Certainly when we were doing hospital budgets, one of the things we did was go back to 2019 to try and kind of gauge a little more normality. So if you have a little bit more information about that, that would be interesting. Yeah, I don't have any insight into what any of the commercial plans are doing for their 2021 program, but I do know that this is the way that I believe Diva's expecting to go. And it also just looking across the other reform demonstrations in Medicare, they're also using 19 as a reference. Thank you. My other question is on slide 24. So with the Medicare Advantage, I think you mentioned this, but I wanna make sure I have it straight in my head. The reason why this is a risk is because you would expect folks moving to Medicare Advantage to potentially be healthier than the folks remaining in traditional Medicare, which would then impact the health of the ACO population. Is that, do I have that right? Yeah, it's the people that we're losing from Medicare Advantage during open enrollment tend to have lower average expenditures. Okay, great. And part of that is they tend to be in Chittenden County, which is where we tend to have better lower average expenditures generally. Okay. And on the care pattern, similarly, we would expect that the out of state care might be more expensive than the in-state care. Is that the dynamic there? Yeah, and it's also just the additional expense of transporting people medically is quite substantial. If primary care relationships move out of state, we do have a way to protect the ACO against that with the QEM exclusion, but it's this tertiary care that would not necessarily go away. Okay, great. I think those were the immediate questions I had. I did, Mr. Chair, I wanna ask Sarah some questions about the discussions with CMS, which I think should be done in executive session, but maybe I should hold off on that until others have asked questions. That would make sense. Thank you, Robin. Jester, Tom. I'm happy to go. Well, Tom, do you wanna go? No, you need me to it. Okay. Sarah, can I ask a couple of quick questions about the 5.5 coming from Medicare premium rates? And I'm just trying to figure out, I actually was doing the same sort of calculation and just looking that up yesterday. And I noticed that part B premiums look like they're going up about 14.5%. And part A, it depends upon, if you've got 30 quarters of experience, not 30, there's a whole bunch of, but even looking at that, part A premiums for people who have fewer than 30 quarters of experience, you're going up 5.7%. I looked at the part B and part A deductibles, they're going up between five and 13%. So I'm trying to really figure out where the 5.5 comes from because I understand that's a weighted, must be some sort of weighted average that you're coming up with related to overall Medicare expenditures. So anyway, if you could just back that out in a little bit more detail, because the part B was going up 14.5, so that obviously must be weighted much lower in your analysis. Yeah, so it's not a weighting issue. If you look closely at the announcement, $18 of the monthly costs are due to uncertainty associated with Alzheimer's drug and uncertainty associated with the pandemic. Both of those things I assumed the ACO would be sheltered from or if not, that would be back on the table. So that was a substantial portion of the increase. The other thing is that I only limited it to the paid amounts, because that's what the contract is with the ACO and the ACO and Medicare. So any cost sharing on the member's behalf would be taken out of this equation. So, and I can totally walk you through the math and even present that next week so that I'm always happy to show my work. Yeah, that'd be really helpful. That'd be super helpful. I noticed December 1st, CMS came out with Medicare spending estimates, looking forward, looking for 21 to 23 and they're at 7.8%, but that's not only, that's enrollees and spending. So I understand it's hard to disentangle the two, but so I'm just, I was trying to figure out, are there other data points recognizing that this, the call letter came out so long ago, but with respect to that also, we're tying, we're all trying to figure out a better number and we're tying it to national trends, but I do think that we have something unique happening in Vermont and I'm not sure how to adjust that experience, but you mentioned some of them and this, is it the slide? No, it's not the slide, it'd be like slide 17, I think might be helpful. Yeah, so one of the things that's notable about, to me about, you know, slide 17, is that typically, you know, Vermont, if you look at it, the deviation between Vermont's experience and the actual experience is quite, is small, right? But in 2020, it was larger. Nationally, it was only down 2% and Vermont was down 7% in terms of Medicare growth, which could be suggestive of, you know, there were more restrictions in Vermont, there was more deferred care in Vermont and therefore the pent up demand might potentially be greater. Granted, that would be perhaps in 2021, but the reality is we're still in this pandemic, it's particularly problematic now, deferred care, we're already seeing kind of being reintroduced because of capacity constraints. We also have the unique Vermont situation of really long wait times, which there is hope that maybe there might be some changes in 2021, I mean, 2022. We know that some of the hospitals are on a hiring spree, trying to hire a more specialist, UVM being one of them, you know, to the degree that some of the wait time backup gets alleviated over the course of the next 18 months. This is something that's happening in Vermont, not happening necessarily nationally. Could that lead to greater growth rates in 2022 as some of that wait time dissipates the hopeful, you know, idea that it might? And then the third kind of unique for Mott piece to me, you also mentioned is the Medicare Advantage and we have a new Medicare Advantage program coming in in Chittenden County and to the degree that they are gonna be siphoning off more of the lower risk population, then what's left is gonna be the higher risk expenses. So I'm just wondering, does it make sense to be using whatever national benchmark new or national trend rate that we might be able to use something like the 5.5, but does that make sense given some of the directional unique Vermont experience suggests that we may be a little bit higher than the rest of the country in the upcoming year because of some of the data that we're seeing. Does that make any sense? It does make sense. And one of the things that I kept thinking about in this is that our recovery in 2020 also didn't look like any other state. You know, while we did go down more, we got back to normal pretty quickly. There was also a cyber attack which is affecting some of these numbers. So hard to interpret what to do with that part of this puzzle. But yeah, I think, you know, any actuary will tell you that uncertainty means higher rates. So, you know, I think it's a tough guess to make. So I can't tell you that I'm right, but I have factored that all into my recommendation. Okay. And then I guess, Mike, related to that and the degree, you know, you mentioned and you've said this and I agree with you 100%, we can't overestimate the degree of uncertainty that we're living with here, right? Like we just don't know. So I'm just wondering why the recommendation might not be for just going with a retrospective trend again, because we're sort of in the same place that we were last year, or maybe worse. Yeah, I think that the idea is that we keep waiting for the uncertainty to go away and it might be with us a lot longer than anyone hoped. And if we're hoping to move to a truly capitated arrangement with Medicare, I think that this is a good way to start thinking through what that might look like even with a ton of uncertainty. Okay. And I guess my last question involves the recommendation you had was for the same rate for NSRD and non-NSRD and when traditionally there's been a differential rate. So I'm wondering why? So I generally the, you know, ESRD is much harder to predict on ESRD. One thing's simple, yeah. But yeah, I mean, there, I think the max rate's a little bit lower. I toyed with going the max rate there, but ultimately it just seemed to add more confusion than help, but yeah, that one's just fit. And as I said, that one's been a lot more stable. So it's, yeah, it's a bit, it's just tough. Okay, at ESRD, their population, their growth rate is stable because generally speaking, they're under constant care, continuity of care because they're so acutely sick that there's not less volatility in there. Yeah, yeah, it's kind of between five and seven grand and there's just a lot of volatility no matter what. It's, I think 140 people have been attributed this year. So it's very few people, which doesn't help. Okay. I think I'm getting it now. All right. That's it for me. Thank you. Thanks, Jess, Tom. So if you could flip back to slide 16. So I just was, I mean, I'm amazed, Sarah, that you can even attempt to keep track of this margin of error and volatility. It's amazing. And when I looked at this chart, I kind of went back to 2018, the midpoint at 877 and then tried to trend that up to 2022 at 1,055. And that's a 4.7% trend. We tried to kind of straighten that out, which seems to be in line with kind of the traditional growth rate. But through all of this nuance, which I couldn't recite if you asked me to, through all of this nuance, at some point the ACO has got enough to negotiate contracts with providers. And I'm just wondering two things is what would you suggest to the ACO in explaining this conundrum to providers in the fact that there's a lot of risk there and where along this timeline will the least, what will the risk be most understood? Yeah, so I do think moving. So one of the things that's challenging about the Medicare population is that it feels like you're never really sure who you're actually accountable for. And that's fair because you might lose a patient who ended up getting 51% of their care in Florida all of a sudden. So they've been totally wiped out. So I do think the more that Medicare can go to a true set population or other methods to have providers have more understanding of their panel or who they're accountable for, that would help a lot in terms of risk. Yeah, I think everyone's feeling it. And I think when I think about risk honestly, like I'm way more worried about risk of capacity, risk of burnout, risks associated with people not getting care they need. I mean, we're seeing some very sick patients right now. And so I really, I would not, I was also saying, you know, if I, I don't want this to seem like it's a, this to me is really not about finances. I just want something fair that makes sense and is going to incentivize providers to make the right decisions with their patients. I think they would do that in any way, but I don't want to get in the way of those, those very important decisions that I know nothing about, talk about nuance, but I don't know if I'm getting at your question, but I guess I think, yeah, I mean, so there's a new variant that's spreading faster, but seems to be less severe. It's possible that that could really clear some of this up in the next calendar year. It's possible we'll have these COVID seasons and we won't know for the rest of the year to year. So I think it's just something, unfortunately we kind of have to wait and see and, you know, but the more that we can move to stable targets for our providers and get away from kind of these claims based noise, that would, I think that would help a lot. And so we, I think Medicare pays a lot of attention to Medicaid's programs and there's some important differences in those populations to account for, but the more that we can kind of go to that unreconciled perspective payment in this program, I think that would help at least take a lot of these, a lot of this noise out of the models, if that makes sense. It does, I just wonder, you know, I kind of look at fee for service sometimes as a comfortable pillow that people are then used to for a long, long time, you know, and that in a time of this kind of volatility, people tend to drift toward what they feel most comfortable with. And so that's why I asked that question about the, you know, ACO and these contracts, whether or not the old, you know, fee for service might be the best for some providers making them feel that's the best place to be as opposed to some kind of a fixed perspective contract that gets reconciled, I don't know. Yeah, the other question I had, and this normally might be a more major question and I recognize this is totally a minor note, but I was looking at the draft. This is not a, you know, a final document yet, but the draft of our annual report and for 2020 has the Medicare cost shift at $247 million and for 2020 and for 2021 at $264 million. It's an increase of projected increase of 17 million. And I'm just wondering how does that fit? How does the Medicare cost shift fit into the analysis that you put together that embedded in the trend rates? Yeah, so. It's a big number to $264 million is a big number. It is, and, you know, the model is always a little tricky because we're really, we're looking at it from the payer perspective and not the provider perspective. So, you know, I think a lot, I'm thinking a lot more care is probably getting in about a state due to capacity constraints. And so I don't know that it's gonna be the most effective tool for addressing that in 2022. Well, thank you and thank you for that. Thank you. Well, thank you and you're amazing. Thank you, Tom. Sarah, can you go back to the slide where you had your projected range? So I look at this range and what am I missing when I see your recommendation at the low end? Is something taken out of this? Oh, so this is all payer. So this, my recommendation is just for Medicare. So this is also, it's got commercial and Medicaid and the rest of it in there. Okay, so that explains that. And then can you go to the slide with the federal estimate? Federal estimate. I thought it was this one, I don't have a right. I think that you went by it already. I thought I heard you say that the federal estimate was for 10.6, did I mishear that? Yep, that's right, yep. Yeah, so the maximum, yeah, 10.4 is the federal Medicare Advantage Estimate, 7.6 for ESRD. Okay, well 8.2 would get us to the 10.6, yeah. Correct. And we have to be at that 2.10 below. So I look at that 10.4 and then I look at the recommendations. What am I missing there, the variance between the two? Yeah, so again, I think anyone would say that that estimate is quite high and that I think the projections initially were really low for 2021. And so the combination of the uncertainty and how their original projections were low for the current year are part of what explains why they are this high for 2021. So again, this estimate was made back in January of 2020. I'm sorry, January of 2021 for calendar year 2022. So they were really estimating two years with no data about those years when they were doing these projections. And yeah, I think that this is really a testament to how much uncertainty the Office of the Actuary had at that point. And it was designed to help folks who were building Medicare Advantage rates. So I think there's probably some reasons why they were gonna err on the high side for their estimates. You talked about you had no fears whatsoever of us exceeding the agreement targets. What is the cushion that we're looking at there? Yeah, so gosh, let me get back to you on that one, Kevin, because I had it and took it out of here and I don't wanna misspeak, so the specific part of it is that range for 21 is so wide, but I can get you the range. Okay, maybe you could just give it to us for next week and that would be helpful. Absolutely. Okay, so at this point, I'll open it up for public comment. Is there any member of the public who wishes to comment on the proposed 2022 Medicare benchmark? Medicare benchmark. So the first, well, I'll call on the healthcare advocate first, Eric Schulteis. Thank you, Chair Mullen. I'm just curious with MA, so setting aside the morbidity issues and setting aside all the madness with estimating 2022 numbers, if Medicare penetration keeps going up it's a population of remaining aligned folks gonna become so small that this potential variance is always gonna be an issue moving forward, obviously not to the same extent that it is in 2022 or is it gonna be negligible? Sir, do you have an opinion on that? It's a great question. I do think we probably, so in some states, it's up to like 80%. I don't foresee that happening here, I could be wrong, but I do think that there's some kind of natural barriers that are unlikely to make the traditional fee-for-service population kind of not credible, but it is hard to predict. Thank you. Thanks, Eric. Next I'm gonna turn to Ham Davis. Thank you, Kevin. I think there's tremendous difficulties, it seems to me, to translate this work which is very complex and detailed but reliable. It sounds completely reliable to me, but the purposes and the use of it strikes me as a real, it's almost sort of a mystery. In other words, what are we actually trying to do here if we, the Medicare is gonna, as far as the provider is concerned, is gonna reconcile anyway. You're gonna get that, so they're not gonna lose money there. But what I'm curious about is, on slide 16, and Sarah referenced this, I think quite strongly that Vermont is very low compared to the rest of the country. And if what we've got is running room here with Medicare, that you can come up to 2.2% with a 2.2 and 2.0, I forget, anyway, a small amount. Why not get that as high as possible is that doable? Because what that will do is it make Tom happy because that would reduce the cost shift. It's, you're not gonna get the full cost, okay? And so one of the biggest overall sort of strategic or geopolitical problems here is how the board can get the smallest hit on the private insurance rates. So can you, Sarah, can you do that? I mean, is that, is it possible to do that? Does Vermont, in other words, get any reward, if you can call it that, for being as strong on slide 16 underneath the national average? Are we just taking money, are we negotiating with ourselves here? Are we just taking away, giving away money and leaving it on the table? Yeah, so I think those are all valid questions. They're probably questions for the board more than for me. I know that this model was started because Vermont was a low-cost, high-growth state. And yeah, I just think, I think these are complex questions. But in my talking with folks in my doing the research, 5.5 seemed like a reasonable recommendation. I'm not knocking your recommendation, Sarah. I'm just trying to figure out what's going on here. I mean, if you take a look at these kind of computations, there are some people they're gonna be able to keep up with you, okay? And they should be blessed, okay? But I just absolutely don't believe that doctors on the ground are gonna do anything different with their patients based on all of this analysis. They're just not. And because they have no idea what it is. There's no doctor out there that's gonna treat a patient today that's gonna have any knowledge of or change what he or she is gonna do based on this analysis. And so the question is really, I just have a lot of trouble, but I agree with you that it's a board question. Yeah, and at the end of the day, the difference between 5.5 and 10.4 using the current estimate is a difference of a less than a million bucks with a 2% corridor. So I think it's, in terms of incentivizing behavior change, I don't know that that actually is gonna be what makes or breaks it. And I'll say, Ham, that it kind of reinforces where I was at last week. Or maybe it was more than one week ago, I don't know. But I have deep concerns about the very low risk corridor. And I think that we're making a mistake by keeping that risk corridor so low. Walter Carpenter. Thanks, Kevin. Hamilton kind of asked a lot of the questions I had, but I wanna, and you just asked another, you just answered another one about the risk corridor. I had one, I wanted to, Jessica mentioned the wait times, which is a great thing. Tom mentioned the risk too, which was great. Sarah is talking about how this whole benchmark thing is from the payers and the providers or for them or whatever. I wanna ask what about the patient? Cause it's the patient that is paying all these numbers, the tax payers, premium payers. And I know the board sick of me saying it, but I'm gonna keep saying it. And then I just wanted to ask whatever happened to the wonderful thing called simplicity. That's a great question, Walter. It's only everything we've learned here, but that's, as we, we threw everything and worked through the mud, we're trying to make sure that the right decisions are made and this is not an easy decision. And at the end of the day, our decision should be based on what's best for Vermonters and Vermonters are the patients. Yeah. And Hamilton is right about the doctors not changing their behavior and that they don't know much about this. I'm a little nervous about the risk, who's gonna be eating it if they come in under budget or over budget or whatnot. And I go back to a company that I worked for where an international company, actually I worked for a division of it where managers got bonuses for cutting, coming in under budget and thus would fire their hire and paid staff to come in under budget. And I just keep, you know, if doctors know they have to bear a risk will they cut in under the patient's care to get that and so on and so forth. That's probably a little bit above this top. Thanks for your concern, Walter. It's an important question. Mike Deltrack. Oops, sorry. Good afternoon. Hey, Sarah, great job. You know, to tee off of Hamilton a little bit not everybody understands everything here but you're really clear and you've done a really nice job. My questions and thoughts are, you know, tie some of the stuff together particularly around board member Holmes's comments about where we are and what we face today as Vermont and our hospitals and patients and everything we're experiencing. I'd like to ask the board contemplate how do we maximize these federal dollars? How do we meet the goals of the model and how do we help providers continue to help patients the way patients deserve to be cared for? You know, there's a lot of what we talked about here but I think at the end of the day we have to maximize that federal dollar and really take advantage of where we're at and the opportunity we have here today and maybe not even be afraid to bump up against the upper threshold of meeting the terms of the model. So I appreciate your time and hearing me out and again, Sarah, really great job. Thanks for your comment, Mike. Next I'll turn to Tom Boris. Hey, everyone. I'm Tom Boris, Vice President of Finance for One Care Vermont. Start by equipping what Mike said or thanks to Sarah Lindbergh. I think you do a great job and I can empathize because this is just really difficult times to be doing this kind of work. It means hard enough to set a target in normal healthcare times and we're far from normal healthcare times right now so I appreciate the work you put in. Just a couple of quick comments. To start with the risk corridor, this is a tough decision, but the risk corridor in a lot of ways needs to be somewhat thought of in tandem with uncertainty. If there's a lot of certainty around the target, good actuarial support, that's a condition in which you'd think about expanding the risk corridor and in that way, you really can tell your destiny a little bit more but as our actuaries coach me all the time with greater uncertainty, you want to narrow that risk corridor. So it's a little bit of a rock in the hard place for us honestly with the blueprint factor and just the general uncertainty. So for whatever it's worth, I wanted to add those thoughts there. The other thought I'd like to add and I intend this in a purely constructive way but to talk about precision a little bit, we go through actuarial exercises with all of these payers every year and we're really talking about very small adjustments that do materialize in a big way at the end of the day but we have a basically a 7% span here and a 2% risk corridor and that's a big span. So I think my common is to think about really like how do we get zeroed in on more precision in the process and get to a target that might have more actuarial support behind it as well to ensure it's accurate for all parties including one care, including Vermonters and including the federal government. We could only answer that question, Tom. Is there other public comment? Is there other public comment? If not, thank you, Sarah. You've given us a lot to digest. Kevin, I'd like to come off this topic. I would like to make a motion to go into executive session. So don't let Sarah go yet. Well, I wanted to thank her in open session, but. Please go ahead with that. And Sarah, as everyone has said, we're always amazed by the work output that you put out and your problem is that you have to get it through some of our thick skulls on how you actually got there and that's not easy. So at this point, Robin, if you have a motion. I do. I would move that the board make a find that premature general public knowledge would clearly place the board in the state of Vermont at a substantial disadvantage in its negotiations with the Center for Medicare and Medicaid Services related to the all-pair model which falls under one VSA 313A1A related to contract negotiations. And also that, well, let's start with the finding and then we can move to the second part of the motion. Is there a second? Second. We had a couple of delayed seconds and. And just to maybe just explain a little bit. My questions so that it's clear to the public. My questions relate to staff conversations with the Center for Medicare and Medicaid Services and negotiating strategy that the board may want to discuss. So that's what I want us to talk about in an executive session. Okay. Is there any further discussion? And Carol, I'll ask if you could put up a sign on this particular meeting site. And Robin, what's the expected timeframe? Do you think? I would say probably, well, we do need to vote on that. And then I need to do a second motion, but I would say it probably 15, between 15 minutes and half an hour. So why don't you put up a sign that we're likely to return at 235, Kara? So we didn't vote on that motion yet, correct? All in favor of the motion, please signify by saying aye. Aye. Any opposed, signify by saying nay. And now Robin for your second motion. Yeah, the second motion is that we move into executive session for the purposes and discussion that I explained previously. And also I potentially have questions for legal counsel. So I would add that to the basis for going into executive session. Is there a second? Second. Okay. Russ, I saw that you popped up on the screen. Did you want to say something before we went into executive session, or you're just getting ready? Nope, just getting ready. Okay. Any further discussion? All those in favor of the motion, please signify by saying aye. Aye. Any opposed, signify by saying nay. Okay, we'll be back at some time after 235. Thank you, everyone. I can now see all board members. So I'm going to reconvene the meaning of the Green Mountain Care Board. And does any board members have any questions? We're going to move on to. Mr. Chair, this is Susan Barrett speaking. Hi. Can we announce that we are having a special public comment period? I didn't announce that before. And I also want to say thank you, Mr. Chair, for the meeting of the Green Mountain Care Board. And does any board member have any further comments regarding the 2022 Medicare benchmark at this time? for on the 2022 benchmark and that is until December 20th in order to be considered for the potential vote on December 22nd. Everything is on our website. Thank you. Thank you, Susan. So next we're gonna move to the 2021 update to the Health Information Exchange discussion and I'm gonna turn it over to Kate O'Neill. Okay. Hi. Okay, so let me share my screen. So you should be able to see my slides here now. Thanks for having me back. We're seeing something that says can't display content. I can see the slides. I see the slides. Okay, so it's just on my end. Let me stop. I'm going to... They're on the website too, right? They are on the website, but I just stopped presenting and let me pull it up again. Kevin, maybe it'll work this time for you. I don't need any when it comes to this. I see of them now, yes. Okay, great. So thanks for inviting me back. This is a... So just a brief... I guess recap of the 2021 update to the Health Information Exchange Strategic Plan and the 2022 connectivity criteria for the record. Kate O'Neill and I'm also on the data team and I'm the Director of Data Management Analysis and Data Integrity. So onto slide two for just a super quick process reminder. On November 1st, AHS submitted the HIE plan to the Green Mountain Care Board and we had a special public comment period posted. And 17th, AHS and Vital presented a summary of the HIE plan and the connectivity criteria. And I provided the staff review on December 8th, AHS resubmitted a revised HIE plan and then we posted that plan to the Green Mountain Care Board website and then we're here today for me to provide some final recommendation to the Green Mountain Care Board and I'm gonna go through it briefly. And then I think you'll see if you're ready for a vote on this. So on slide three, Board members expressed an interest in an effort to develop what really amounts to a data strategy and also visioning around the balance between public and private investment in the VHIE and seeing these as important guideposts for the development of the next comprehensive five-year strategic plan. Those comments and those concerns have been addressed in this revised plan. We also received verbal public comments at the November 17th meeting and that centered around consumer representation and provider input into the HIE plan and connectivity criteria with concern about costs of subscription services being passed on to consumers and consumer access to the VHIE related to ease of access through one portal. We did not receive any written public comment. So on November 17th, I'm sorry, after the November 17th presentation to the Board the HIE plan was resubmitted and the changes or the updates are summarized here essentially that the HIE plan and the HIE steering committee will work to validate that goals and objectives for the health information exchange in Vermont represent the needs and interests of health systems stakeholders that it further develops the vision for sustained public investment in the health data exchange infrastructure and opportunities for private investment. And reviewing the HIE steering committee membership and governance structure just to make sure that the essential roles are filled and that the structure and the organization really emboldens the progress that the HIE steering committee is looking to make going forward, particularly because this is a transition year really in next year's update, it's really gonna be a comprehensive, it's gonna be the next five year plan. And so this is a really great opportunity to just make sure that the structure and the organization is really solid. Also addressing HIE governance in Vermont and developing a data strategy to provide consistently updated description of how and why data elements are aggregated and shared through the central data repository which is the health information exchange. And just, I just wanna say a little bit about the data strategy thing. It's a common term and it is used commonly in the comprehensive data space and it can be designed uniquely but there are common elements to it. So when we talk about a data strategy what we're really addressing in a sort of a general sense is that there's a written document that addresses the needs and the requirements of the health data system with goals and objectives including stakeholders and how those stakeholders are engaged. And addressing the technology infrastructure requirements, how to take that data and turn it into information that's information that's understandable to the general public. And of course data governance is a part of that. And finally, a data strategy includes like a roadmap so some way that you can see data is ingested, data is used, data is shared and a timeline for that. So that's kind of a rough sketch of what we mean when we say data strategy. What that data strategy will look like as developed by the HIE Steering Committee and Vital going forward will be unique to us here in Vermont. And the intent is I think to foster a closer relationship between the HIE Steering Committee and the Green Mountain Care Board's Data Governance Council. So there is some interest in understanding progress going forward through the year. And we thought that that would be a good opportunity for the Data Governance Council to engage and provide feedback and allow for that discussion to take place. So there's a super quick reminder of the principles that we use for the HIE Plan Review just to make sure that it aligns with statute and whether the HIE Plan meets the goals of other recent relevant legislation whether the HIE Plan incorporates national best practice and stakeholder input. We do think that the HIE Plan as revised and resubmitted is, it has been strengthened in these areas. To that end, the staff recommend approving the revised 2021 update to the Health Information Exchange Strategic Plan as resubmitted on December 8th. And there also, we also need to remember that we've got the VHIE Connectivity Criteria to vote on and we use two principles for the Board's annual review on that and that's focusing on alignment with the HIE Plan goals and clarity of the criteria themselves. There was no additional comment on the connectivity criteria since we presented last time on November 17th. And to that end, the staff recommend that the Board approve the 2021 connectivity criteria as submitted in the 2021 update. That's it for me. Russ, can this be done in one motion or does it require two? I think it could do it in one motion. Robin, do you wanna take a crack at it? Sure. I move that we approve the revised 2021 update to the Health Information Exchange Strategic Plan as resubmitted on December 8th and approve the 2022 connectivity criteria as submitted in the revised update to the plan. Okay, is there a second? Second. It's been moved and seconded. I'll open it up for Board discussion and I will throw it open to public comment before we vote. So any member of the Board at this time? I just have one quick question. I thought in what we saw at our last meeting on this that there was a phrase in there on a timeline to begin to enumerate the types of social determinants of health that were going to be activated in a way. And I didn't see any of that mentioned in the slides that you just presented. Yeah, so that is addressed in, I'll be a more general sense in the update to the plan. And we thought that a good place for that to happen would be with the Data Governance Council which is why I mentioned that there would be more engagement. So rather than the HIE steering committee coming back to the Board say in three months or six months with social determinants of health enumerated and other specific requests from the Board that they would work with the Data Governance Council and the Data Governance Council could provide an update to the Board as needed. Any other Board questions or discussion? No, thank you, Kate. You did a great job and my concerns were addressed in the update. So hearing none, I'm gonna open it up for public comment. Is there any member of the public who wishes to comment? Ham Davis. Yes, thank you, Kevin. Puzzled about the whole data situation thing in the October 27th, that consultants report that was very important. They went on to sustain the basis of the sustainability project. They had the hospital costs, they had hospital costs, for example, they had no doctor costs. What I'm curious about is back in the 1980s, 1984, the state health department had almost complete data on hospital spending. Now that doesn't, that's not all healthcare spending, but it had certainly had all the doctor numbers in it and it formed the basis for the Dartmouth Health Atlas, which is one of the most important references. In 1980, the state of Vermont could crack every virtually every single number that went through hospitals using these Jack Winberg small area variations technique. Do we need that now? We have this huge bureaucratic blizzard of stuff, but what do we need to have in Vermont? It seems like if we're gonna have a state that is genuinely moved to the forefront of reform and gets to, and gets really the change from really shifts from fee-for-service to capitation and then begins to look at all kinds of questions that result in that on the performance of the delivery system itself. Then what are we looking for here? I think that we need to go back to the Winberg data it was, I think it's far more comprehensive than what we have now. Does anybody agree with that? My understanding of the Dartmouth Atlas and maybe if Sarah Lindbergh is still here, she could chime in, is that it's Medicare only. So that information, I think we still have. But, and I'll say, I see Sarah, so I'll pass it to her because she knows way more than me. Yeah, I think in my opinion, Mr. Davis is right on the nose in that that's exactly the type of analyses that we think would help with the board's decision-making and it's definitely in the pipeline. He did just use Medicare, so translating it to all payer methods is something that is under construction. Thank you very much. Kevin, you're muted. Hearing no further public comment. Is there any discussion before we vote on the motion? Hearing none, all those in favor of the motion, please signify by saying aye. Aye. Any opposed, signify by saying nay. Let the record show that the motion carried unanimously. Thank you, Kate. Doing a great job taking over for Sarah on this one and we appreciate it very much. So now we're going to turn to the all payer model agreement proposed extension and I'm going to turn it over to Sarah Kinsler. We can barely hear you, Sarah. Really? Yeah, it's better for me. Yeah, I see nodding heads. While I wait for my presentation to load up on the screen, I will just say that I also would like to extend my thanks to Kate for so ably taking over the HIE plan. All right. The presentation is on the screen so you're all set. Excellent, thank you. So to introduce myself, Sarah Kinsler, GMCB director of health systems policy and I am here to give an update on that proposal to request a one year extension of the current APM agreement and we also have a potential vote noticed for today on this topic. So this slide shows a recap of where we have been so far on this on December 1st, Ina Bacchus and I were before the board to describe a proposed request to extend to the current APM agreement by one year through 2023. I have linked the materials that we walked throughout that meeting on the slide. As discussed at that meeting, this proposal doesn't intend to replace a proposal for a longer term subsequent agreement likely for a standard five year term, but it does give us some more time, especially in light of COVID-19 and the pressures facing the healthcare system and especially our providers to do meaningful engagement about what that next agreement could look like. So since the first we've had one suggested addition to the materials we shared then, and actually it would not be a point of discussion around the proposed extension but a waiver that we are stating our intent to request under the current agreement language. And this proposal would allow Medicare reimbursement for a broader set of master's level clinicians, specifically those who provide mental health and SUD treatment services. And it would also be in line with the providers that Medicaid reimburses. This has been something that has been floated a number of times and has been discussed by the Vermont signatories and stakeholders to the model. And I know that Ina Bacchus is in attendance today and can speak to any specific questions that board members might have around this addition. I've also linked here the updated request letter, which is also in the meeting materials on our website. So in terms of proposed next steps, if the board approves moving forward, the draft request letter would be finalized and submitted before the end of the year. I do wanna stress that this would be the start of negotiations between the state and CMMI around a one-year extension. So we would be back before the board sometime in 2022 with a legal document developed to kind of out of whatever we negotiate, which we would be asking the board to consider and on which we'd be soliciting public comment and engaging stakeholders. As we said last week in response to questions, we'd be looking to move forward fairly quickly or not last week on the first, I guess, in response to questions, we'd be looking to move forward fairly quickly on these negotiations so that we could shift our attention to the longer-term renewal, which we recognize will be a big lift. This slide summarizes the public comment that we have received so far. We received three at the December 1st board meeting. We have one written comment from Alan Oxfeld, which is posted to our website, as we traditionally do is all. So here I have listed a staff recommendation. The language is to request a one-year extension of the current all-peer model agreement as presented on December 1st with the addition of language regarding mental health and substance use disorder treatment providers presented on December 15th, 2021. Thank you, Sarah. Do any board members have questions for Sarah? I don't have a question, but I would just comment on the mental health and substance use disorder treatment issue. I think it's great to include this because as we know, and as was recently heard from health care, we're, you know, there's just a real need right now. And so allowing Medicare folks to have broader access through an expanded type of licensing clinicians, I think would be a real benefit for Vermonters. If I might add, it's also in line with our all-peer model agreement targets for population health and quality. And more importantly, it's in line with the stories that we're hearing from the field about the increased pressures due to the pandemic on these areas. And, you know, it's something that we're going to have to deal with. So are there other board comments or questions? Hearing none, I'll open it up for a public comment. Does any member of the public wish to comment on the proposal for the extension? Walter? Just thanks to Robin for bringing up that mental health issue. We all know practitioners in the field they just scream about how short-handed they are. That's all for now. If only we could magically produce more. Well, Robin's right on that one. Yep. Is there other public comment? Hearing none, Robin, would you like to make a motion? I would. I move that the board support a request for a one-year extension of the current all-peer model agreement as presented on December 1st, 2021. And also that the cover letter include the request to add, to that the cover letter include the request regarding mental health and substance use disorder treatment providers as presented today. Is there a second? Second. It's been moved and seconded. Is there any further board discussion? I'll just briefly note, I think I said this on the first when we talked about it that I think there has been some confusion around the continuation of the agreement and whether or not we have Medicare participating ACOs in the state. And so I just wanna again, emphasize that to me the having the state have some say in the Medicare ACO programs and in the direction that Medicare is going is important because I think even if we didn't have an agreement, we certainly are seeing Medicare ACOs entering the market, even absent those which are focused on the APM. Okay. Other board comments? Any further discussion? Hearing none. All those in favor of the motion, please signify by saying aye. Aye. Any opposed, signify by saying nay. Let the record show that the motion carried unanimously. Thank you, Sarah. Thank you. So don't go too far because next we're gonna move to a discussion on the fiscal year 22, one care Vermont ACO budget and certification and I'll turn it over to Sarah, Marissa and Michelle. Good afternoon, Mr. Chair and board members. Sarah has delegated today's presentation to myself, Marissa Melamed and Michelle DeGree. We also do have the full team here. As you'll recall, we went through a full comprehensive presentation of our analysis of the FY22 ACO budget and certification last week and we're back this week to go over a few issues that remain from last week and some updates to our recommendation. So Michelle and I are going to present those and we can take questions on them as well as we have the whole team if needed. There's no vote noticed or expected on this today. It's just to bring these updates before you and the public and we have a vote expected or noticed, I should say for next week on the 22nd. I'm gonna go ahead and share our slides. Just give me a second. And we see them. Thank you. All right, a minute to catch up there. Okay, so just quick introduction. We did not receive any additional public comment between last week and this week to consider but the updates that we're presenting to you today are based on the board discussion from last week. Some clarifying information that was received by us from OneCare, which you'll see in the presentation and we have some staff identified clarifications that we will discuss. So the first one is around really the heart of our new recommendations this year. So on 12-8, we presented this recommendation that you'll see up on the screen around the implementation of an ACL benchmarking system. We had some staff level discussion and wanted to provide some more specificity around this recommendation based on the conversation that was had. So we've edited this recommendation to more clearly state the objectives of what we're trying to accomplish and to provide that specificity. So the updated recommendation here is a little longer but I think it's clearer and I'm actually gonna go ahead and read it because it's possible not everyone has had a chance to take a look at this. So the updated recommendation is that OneCare must implement a reputable and effective ACO benchmarking system to compare key quality, cost, and utilization metrics to national benchmarks, utilizing OneCare claims data and potentially clinical data and acquiring data from third-party sources as needed. The benchmarking system and data source must be approved in advance by Green Mountain Care Board staff built for each payer program and include national benchmarks regional if available and identify best practices based on the data in five key areas. One, utilization, two, cost per capita, three, patient satisfaction and engagement, four, quality, and five, evidence-based clinical appropriateness. The benchmarking system will allow the ACO and the Green Mountain Care Board to assess OneCare's performance against peer ACOs or integrated health systems, enhance OneCare's ACO-level performance management strategy including implementation of processes and programs that have been implemented at best practice sites and integration of these priority opportunities in the OneCare quality evaluation and improvement program and improve ACO regulatory reporting and performance assessment by providing the benchmarking comparisons to targets at least quarterly to the Green Mountain Care Board. Implementation of the benchmarking system shall start with the Medicare program in FY22 as a test year. OneCare must select and propose the Medicare benchmarking system for GMCB staff approval by April 1, 2021 and present the Medicare proposal as well as a plan for Medicaid and commercial benchmarking systems at their revised budget presentation in spring 2022. Monitoring dashboards and targets will be developed by Green Mountain Care Board staff in collaboration with OneCare and specified in the updated ACO reporting manual. The updated ACO reporting manual will be modified by Green Mountain Care Board staff to streamline reporting requirements to be more focused, sorry, to be focused more on results of the benchmarking system. So again, the heart of this recommendation is to help us move towards more of a results-based reporting based on data and national benchmarks. This is not new. The desire to implement some sort of performance dashboard to allow us to evaluate ACO performance has been part of the discussion for the past several years. We engaged with a consultant to help us formulate this recommendation and between last week's discussion and a little bit more internal work, this is where we've landed on that recommendation. Moving along to the next one, we received some comments. I think these came from Board Member Holmes during last week's meeting. I think these are pretty straightforward, but just wanted to highlight what the changes were to expectations for OneCare's revised budget presentation in the spring. Board Member Holmes recommended that we include, like I mentioned before, H, which is the status of the ACO benchmarking system by pair program, so it's kind of in here double now. I is an update on the results of evaluations as described in the FY22 budget submission, including care coordination and analysis of variations in care by HSA, which were two evaluations that were mentioned in the budget submission, as well as an update on the partnership between OneCare and the University of Vermont, the academic institution to explore additional partnerships around evaluation. I and J are really both the requirement to come in and talk about OneCare's evaluation program. So those were suggested updates to call up specifically for the presentation, which we felt fit with our staff recommendations, so we have included them. And finally, this is really just to be kind of aligned with the benchmarking recommendation for accuracy, but we updated the recommendation around the operating expenses that they must not exceed a 15.3 million in the proposed budget, plus the cost of the third party benchmarking system as required in the, I believe it'll be condition one, but we'll fill that in later, following approval by Green Mountain Care Board staff. And this has been estimated at under $100,000, but again, it's subject to approval by Board staff. So those are the three recommendation updates that I'm gonna talk about, and I'm gonna turn it over to Michelle DeGree to talk about the Value-Based Incentive Fund discussion and recommendations. Thanks Marissa, I'm just gonna adjust my volume here. Okay, can you all hear me okay? Okay, for those who don't know, I'm Michelle DeGree, I'm a Health Policy Project Director here at the Green Mountain Care Board, and as Marissa said, I'm gonna walk through what the staff have come up with for the Value-Based Incentive Fund discussion and sort of our recommendation at this point. I will say that while all of the recommendations are no easy feat, this one certainly took a toll on the staff and we worked pretty hard to come up with it and you'll see that ultimately we landed on sort of offering the Board two potential avenues. That's not to say that there couldn't be more. So I'll sort of walk through the way that we got to those recommendations. So Marissa, if you could move to the next slide for me. So again, this is a slide from last week, just reminding you of the four sort of programs. And we are focusing today on the Value-Based Incentive Fund. So again, last week staff had noted that we were likely to increase, to suggest an increase to this funding stream just based on the reduction that's seen in the budget. And as Marissa mentioned throughout the past week, we received clarification on some existing funding streams and that are tied to quality and I'll sort of review those with you in the next couple of slides. So Marissa, you can rest, you can rest, you can rest, you can rest, you can rest, you can rest, you can rest, you can rest, you can rest, you can rest, you can rest. So I think it was coming through Marissa's line but it looks like she's muted now. So I think we're all set. Okay, okay. I do have the tendency to break teams meetings. So you never know. Okay, so again, this is from last week. So just another sort of overview of it, the VBIF 2022 proposed amount is a million dollars flat and that's an all payer amount. And just to remind you the value based incentive fund priorities are the same as the clinical focus areas and those four are listed on your screen. Marissa, you can hop to the next slide. So this is what staff have been working on putting together. So this is our best effort to distill sort of a great deal of information into the most digestible format that we could come up with. So this is comparing, you'll see in the columns, 2021 budget to 2022 budget amounts in the programs that are specifically tied to quality performance. So I'll sort of walk through. So we've got it broken down by the different categories or in your rows. So you have the pre-funded value based incentive fund. You have the quality accountability at settlement. So that goes back to the settlement conversation that we had with the payer panel at the end of November. And then you have the population health management investments that are linked to quality outcomes specifically. That's sort of a newer change for this year in lieu of the changes to the care coordination program. So I'll try to walk through them the best I can, but I think what staff decided to do was really note on this slide the key takeaways from each of those three programs. So for the pre-funded VVIF sort of in its name, it's pre-funded, that is a fixed amount. It's much more timely and it's linked to one care's clinical priorities. For the quality accountability at settlement, the numbers on your screen here is max available funding at settlement. So there is the potential to not meet this threshold too. So I just, I want to flag that. And also note that those are budgeted amounts. And again, if you'll recall, we just did 2020 settlement. So what you're looking at here is the amount for the program year that we're in, but won't be realized until late in the following year, which is the point in the key takeaway. So it's a variable amount. Again, it's based on the score earned. There's 12 or more months-ish. It can be up to 12 months removed from that performance. And this specifically as you're aware is linked to payer contract measures. And it additionally has, so there's 10, 70% payer contract, 10% is tied to the performance improvement program. And that's 10% of the settlement. And the performance improvement program has two measures specifically. Those are cost per capita and avoidable ED utilization. And then the other 20% can be voted on by one care's board. And then for the PHM investments linked to quality and outcomes, again, this is a fixed amount. It's a pre-funded amount. So it's much more timely, just like the VBIF. And this is specifically linked to care coordination measures. I will note that those measures per the budget submission are not yet defined. We think probably given just the general kind of world that we're in right now, but I'll let one care speak to that. I think I saw that Sarah Berry was on the line. So I don't wanna speak out of turn, but I think it's very likely just due to needing to kind of have committees to find those measures and be able to set those in place. So we didn't see those in the budget and are not aware of what those measures are at this time. I think just to sort of show you here the difference between the 2021 and the 2022 budgeted amounts and the overall change. So you see there is an increase of $154,044 between the two years. I will say that the higher overall potential earning is possible, but there's a actual smaller pre-funded amount if you do the math than in fiscal year 21. So because that variable amount, so the settlement amount goes up between the two years. So that's really where you're seeing sort of that change. I'll give folks another second to look at this. I know there's a lot of information. And then Marisa, you can go to the next slide. Thank you. So based on the information that we have worked on from our last presentation, sort of revisiting the budget, we came up with two recommendations to bring to the board. So the first recommendation is that in fiscal year 2022, one care must fund the VBIF and an amount greater than or equal to the fiscal year $21 amount, which as your call was $2.24 million to be reflected in the final budget submission due in the spring, just because we know that some of that is tied to a payer negotiation. So we wanna make sure that we let all of that sort of flow through and we ask them to see that in the spring. And option two is kind of not really recommending a condition here, it's just based on the information that we received in response to our last board meeting, we could leave the line item as is in the budget, which again is the million dollars and continue to monitor those total quality incentives available as you saw in the last slide, which is greater than the total and unavailable last year by about $154,000. So sort of continue monitoring how those investments flow and being less strict about the line item for VBIF. So those are the two sort of extremes I guess where staff landed. Marisa, you can go to the next slide. Thank you. I'll just close us out since I'm here. So again, we have presented to you on December 8th. This is sort of the wrap up of our staff recommendations next week, we have a vote noticed and so any conversation that comes from today's presentation on our updated recommendations and any incorporation of public comment that we received by that time, which I believe we noticed until the 17th, I'm looking at Marisa for a nod or a, okay. Yes, to be able to incorporate any feedback that we received through public comment at that time and we'll come back to the board next Wednesday with any changes to these recommendations for a potential vote. Just a reminder that the vote needs to occur before December 31st, 2021. The green, the green highlight is deceiving. We were joking about this yesterday. It makes it look like we're not very far along, but I promise we're nearing the end, we're getting there. And so Marisa, I think the next slide is just public comment, yeah. So I'll stop there and turn it over to you, Chair Mullen for any questions or comments from the board and the public on the updates that we provided today. Thank you, Michelle and Marisa. At some point, before we go to public comment, I'm gonna wanna hear from OneCare on their thoughts and board members, if you want to ask any questions now or any comments now, feel free. Otherwise you can wait till after we hear from OneCare. I'll just make a comment because I'd be interested in OneCare's reaction to my comment, so I'll make it now. To me, I think what I would be interested in understanding is why we wouldn't wanna double down on quality in this particular year, given what we know about the pandemic and the impacts of the pandemic and the fact that as discussed earlier, the risk is relatively low, but we do know that quality is really at risk. So I'll just state that I personally would be inclined to level fund the quality in the VBIF or an equivalent amount in a different program if that makes more sense. Like I don't feel like I necessarily, that I personally might know the best program, but to me, the important features of the VBIF is that we know what it's tied to already before we enter into 2021, which means the providers know what they're working towards. It's pre-funded, so one of the big complaints I've always heard from providers is the quality incentives don't work if they're a year after you've already given the care. And so those aspects of the VBIF, I think are a stronger incentive. I'm willing to be told I'm wrong about that for sure, but those were my thoughts that I just wanted to share. Any other board member thoughts or questions before I ask one care for their comments? Go ahead, Jess. I went first last time, go ahead, Tom. I have just one, the slides having to do, the last time we met having to do a benchmark includes the phrase less green mountain care board focus on granular budget line items, more focus on the results. And so that's a broad statement. I am generally supportive of result space budgeting and the benchmarking effort, but I also agree it's a two-way street that one reason for moving there is to make the overall operation more efficient our operation. And so just kind of from my perspective, just saying to the ACO, if you see areas that you think we're asking efforts of you that aren't kind of consistent with the benchmarking approach, let us know. I mean, it's very hard for people to let go sometimes in a budgeting process of what they're used to and we're used to where we've been so far, but we're trying to turn the corner here and want to do that with you and you will have the insights on the other side of the table as to things that you might suggest we let go of. Hey, Jess. Yeah, I'm just gonna say, I'm hoping to hear from OneCare a little bit more detail around that 982,000, specifically a little bit more about the outcomes that are gonna be tracked there, how much of those are related to clinical care? That's what I'd like to know. So I do see that Sarah Berry has her hand up. Are you gonna speak on behalf of OneCare, Sarah? Yes, Chairman Mullen, thank you. And I wanted to start both by recognizing Board Member Pelham's comment and appreciating that that in combination with the work that the staff to the Green Mountain Care Board have done over the last weeks to really dig deep into some complex information is greatly appreciated by OneCare and we also are appreciative of kind of the spirit of trying to make sure that the information that we produce and provide is really helping the overall system and ultimately helping Vermonters, not kind of creating more work for OneCare to generate and the staff and the Board to review without necessarily a direct correlation with improvements in care or outcomes. So thank you very much for that. I did wanna start by just recognizing that the ACO as a provider led reform effort is really guided by provider feedback and a need to evolve programs and policies at a pace that we feel we can maintain our provider participation and continue to increase accountabilities. So we've spoken before about kind of the foundation being set over the first years of the model and now OneCare is very focused through its governance process and in conversation with providers about clarifying and holding our network to specific accountabilities. The challenge in all of this from our standpoint is that if we move too fast or too hard, we will lose a significant portion of our network which will obviously directly impact scale one of the state's key goals in this area. And so really what we're trying to do is find that sweet spot and recognize that that sweet spot can move a little bit from year to year as we work to both evolve quality but to do it while also thinking about our overall population health management investments and our risk models. So really wanting the Board to hear from us that we are thinking about all three of those things and how to move them forward in a path that really can get us hopefully beyond the pandemic and into the pathway that we all want to be on for realizing true large-scale accomplishments with value-based care transformation. With respect to quality specifically, I just wanna acknowledge that I think we caused some confusion in the larger environment with our label around the value-based incentive fund because we have evolved its meaning over time. And so what we mean by it today really gets to some of the core tenants that Board Member Lunge was speaking about in terms of being specific and measurable and timely. And so that is where we are focused on those four key quality measures and feel like the timeliness of incentive in relation to the data and the performance expectations is critically important. At the same time, we had some pretty intensive conversations with our provider network this summer about an equally important investment in care coordination. And when asked to make some really tough decisions about where those priorities should be set and how to align them, there was a feeling that Vermonters that are eligible for the complex care coordination program are amongst the most vulnerable in general and probably even more so because of the pandemic. And so it was felt that trying to maintain that at the optimal level, given the reduction in state and federal funding to support these efforts was really the best place for us to have a positive impact as we look at 2022. So with that, I would say that we wish there was more funding available and more opportunity whether that be through state and federal funding sources through payers through others to be able to invest more in the value-based incentive program. But this is really where we felt there was a reasonable threshold for 2022. And in tandem, as Michelle described, what we've chosen to do is to allocate almost a million dollars into the quality incentive as part of the care coordination program. So there were a couple of questions about that that I wanted to address. The first, I wanna make sure that it's clear that those dollars that 982,000 goes to primary care as well as the continuum of care. So folks like Home Health and our designated agencies, we were hoping to have the measures set this month so that they were ready to go, but some of our provider associations have asked us for a little bit more time given some of the workforce challenges that they're having. And we felt that was reasonable to continue working with them in January to accomplish that goal. To give you an example of the conversations, we're trying to work to customize where each segment of our network can have the greatest impact. So for example, the quality indicators or outcomes that we might track with our designated agency partners are likely to focus on mental health measures under the all payer model. Whereas in our Home Health agencies, it's very likely that it might look at more their ability to help us avoid unnecessary utilization of the emergency department or to keep people out of the hospital in the course of receiving skilled care. So we'd be happy to report those specifically back to you in the month of January or thereafter as they're described. But I think overall we come very close to that investment in terms of if you were to compare the value-based incentive fund for 2021 to the two components that are being paid in a timely manner in 2022 being the population health management quality investment related to care coordination as well as the VBIF. With respect to the benchmarking, I just wanna comment that I think there is still some opportunity for clarity about the multitude of uses for such a tool and that I recognize that one of those uses is really through a regulatory lever in thinking about the ACOs performance relative to other ACOs nationally. And then there are others that are really more within the purview of the provider network and how they want to receive data and be able to look at best practices. And so we're really looking for opportunity to continue to improve and to continue to focus on one of our core capabilities around data and analytics but also doing it in a way that is really provider led and provider directed around how they want to spend the resources and how they want to focus those efforts. So I think I'll stop there and I'm more than happy to answer any follow-up questions if I didn't get to them or if any further came up from my comments. Do board members have any clarifying or follow-up questions? Thank you, Sarah, that's very helpful. I would say that certainly should the board choose to go in the direction of requesting an increase in the quality components. Personally, I would not expect that to be at the expense of other programs. So I think you'd have to find that funding from a revenue source in some way. And I personally wouldn't necessarily dictate how you do that, whether that comes from settlement dollars or whatever, I don't care. But I'll just say that certainly that would be my intent just to express it. And I certainly understand you're trying to balance different components of your budget and kind of meet where you think you're gonna land in your payer contracts. Yeah, thank you, Board Member Lange. I think I would just comment in return that the challenge for us, I understand that the board's responsibility is to look at the entire system. Ours at OneCare is to look at what's within the purview of the ACO. And so we have a limited budget and limited resources that have become much more constrained through the loss of delivery system reform and HIT. And so I just think it's challenging, as we all know, given the times that we're in and would ask for some grace in that process around making sure that we can keep supporting our network as lean as we are without putting more constraints on them at this point in time. Are there any other further clarifying or follow-up questions? If not, thank you, Sarah. Do board members have any comments at this time? Hearing none, I'm gonna... Oh, sorry, Robin. I didn't mean to cut you off. I was deciding whether or not to jump in again or not. But I think, you know, for me, I certainly understand the financial pressures and the loss at the state dollars, although we knew those were coming. We've known that since the beginning of the last global commitment waiver that those dollars are being phased out over time. And I'll just say personally, I do think having increased dollars in quality is important to me. So I am likely to support the staff recommendation for that additional amount. I'm willing to leave it up to one care as to whether to invest that through the VBIF or the Care Coordination Program. To me, the core tenants that I said before, the important parts that it's clear to providers what they're working towards that they get those dollars in a timely fashion, et cetera. So I think if we were to not be as specific, but to kind of lay out those components, that would satisfy me. I'd want to be clear that that money should not come out of other programs. And also I think it's just important to note that by doing so, we're not trying to dictate any particular result at any payer negotiations. That's obviously, we leave that to the payers and the providers, but that this is an important part of the program. Hey, other board comments? Hearing none, I'm going to open it up for public comment. I'm going to call on Dale Hackett. So, first of all, Robin, thanks. I totally thank you for making those comments. I think that's really important. Secondly, I'm still a bit puzzled. Can somebody help blame? You've got provider led, but you got a share of providers. You kind of cut down on ED visits, but because you've got a shortage of providers and people really can't get into that doctor's appointments, they may actually call up and be told to go to the emergency room department because they can't get a doctor's appointment. How does this, how does this work from how the data gets recorded when it's a type of scenario for one care? Because they were talking about cutting down on ED visits. And so, some are cleaning here, as far as I get the goal, but is there a real list? So, Dale, you're cutting out a little bit on my end. If I think what you're suggesting is that because there's a problem with access that there's more demand on emergency visits and maybe staff heard more of what you said. If you did, feel free to answer Dale, but unfortunately, I had him cutting out quite a bit. Marissa and Michelle, did you hear what he had to say? Yeah, cut her right now, or no, okay, sorry. Marissa, no. Go ahead, Michelle. I don't know, Marissa looked like she was trying to unmute. I think we're both deep in thought about her response. So I think if I'm understanding correctly too, I also heard how do we sort of balance what seem to be positive indicators of quality being things like reduced ED visits with things like pent up demand in the system and having highway times. And that's a really good question. And I think we'll continue to monitor all of this through our all pair model federal reporting. And I think one care will have to do it, do diligence at sort of monitoring that as well. I think the other thing that always comes into play here that we have to weigh is as scale changes, the population tied to the ACO also changes. And so we are also always aware of sort of that shift and kind of following those participants risk levels and keeping all of that in mind as we continue to monitor and measure. So I know that's not a super straight answer to your question, Dale, but it's what comes to the top of mind. So I'll stop there. Okay, I'll call on Walter Carpenter. Thanks, Kevin. Just wanted to back up what Robin said about quality. She's already said it. So I won't say it again. And I also wanted to ask Michelle, will the ACO actually mitigate wait times at some point? And then there's a comment on the public comments about the one care budget by a G. Richard Dundas. And he asks, please show us the evidence that the value of care has improved since one care began operating. And I just wanted to ask if that is possible, because so far we have long wait time, we all know we have long wait times, et cetera, quality value has it improved. Michelle, you wanna take a crack at that since you're the measure of quality? Sure. So I think a couple of things just to flag and note that another piece that I didn't mention in my prior comment with timing of this, right? So if we're using claims data as the basis for most of our measurement, some of this takes time. I think a big piece of what you're speaking to, Walter, is we have to consider the pandemic, right? So this is a huge potential kind of doing the research now, but what demand did that cause in the system versus what demand was already there? And in addition, the provider sort of shortage, if you wanna call it that, from all of the other research that's going on in the state, that's not ultimately one care problem to solve. That's gonna be sort of a collective effort between a lot of state partners, I think. So I think it looks like Sarah Kinzler has something that she might wanna add. So I'll turn to her, but that's sort of just the basis that I would say in responding to your questions. And again, I know it's sort of a higher level answer, but I can't give you great details at this point, unfortunately. Well, I think the part of the issue I'm here is that these problems were going on before the pandemic. There was a physician shortage before the pandemic and the pandemic, of course, has just exacerbated all of the problems that were there before it came along. Sarah, did you wanna add? Sure, and I completely concur with Michelle on all of the points that she made. To your point on the physician shortage and the workforce challenges that we're seeing now, Walter, these are things that we were working on in the state innovation models grant workforce workgroup and the workforce strategic plan that came out, I think in 2013, that we put together with partners from all over state government and the public and so many stakeholder groups. So these aren't new challenges, but they are really significant right now for so many reasons, including the pandemic. And it's gonna take more than the ACO to crack that nut. In terms of demonstrating value, as Michelle said, there are, even though we are four years into this model, data-wise, we are in year two or coming into mid year three. So we are always gonna be a little bit behind as we look at that data. And we need to kind of give ourselves time to learn from what we're seeing. That said, we've presented last week on some of the results that we've seen to date. Many are promising, some are mixed. It's clear to us that there are both areas of success and areas for kind of collective improvement. One of the things that I think it will be really beneficial about the monitoring strategy that staff are recommending going forward, this kind of tie to national benchmarking and tie to national peers is that it will help us see more clearly kind of what should we, what kind of performance could we realistically push for? What kind of standard should we be holding ourselves to in terms of what are the best performers out there doing and how can we make sure that those are our goals? So I think that will just give us another frankly, much more timely data tool to have in our pocket as regulators. Okay, next. Thanks Sarah. Oh, go ahead. No problem. Next I'm gonna turn to Ham Davis. Thank you, Kevin. The whole issue of quality it seems to me is one of the single most important issues in healthcare reform and has been for a very long time. And what bothers me most about it is the very significant aura of unreality that surrounds all the talk about it. For example, there isn't anything that one care can do about health care quality and from fun, not a single thing. They don't put on a band aid and they don't prescribe an aspirin. Every issue, every issue of medical quality depends on the performance of the state's 15 hospitals and it's 900 or so doctors. They are the ones that have to do it, okay? And the question is how you begin to get into that problem. And so the one care can collect data that you tell them to collect, but that's all they can do. They can collect data. And the single most important sentence that Sarah Barry said is that if her hospitals don't like what she's doing, they won't be part of one care anymore. Think it through. That's reality. Somebody who thinks they can get just sort of maneuver by some sleight of hand to get by that problem is just a waste of time. So the question is, the question is, what if you get the data, what the board can do is, what can say here's the kind of data we wanna see and you can ask for the data, okay? But what will happen is then you can count on it, okay? Is that the people, that people as they put that data together, the issue will be whether if you have a problem with quality, that you locate that you'd say, who's the problem? Is it hospital X? Is it doctor Y? You'll have a huge impulse inside of medicine that's been true for 50 years, okay? The doctors understand perfectly that their performance is mixed. They know that. The thing they want last in the world is somebody looking over their shoulder and telling them what mistakes they made. You think they really want that? Do you folks want that? Does anybody want that? So the question is how to get by this conundrum. I mean, it's not that it's really hard. Actually, in the level of the whole quality industry now is still pretty weak. It's mostly filling in boxes. Did you make this telephone call? Did you ask the patient whether he ate this or that? Very little outcomes in there. And even there, you can't get it. For example, I've tried for five years to find out what the level of revision surgery, not return to the OR, which is what they want to do because that doesn't tell you anything in Vermont. Revision surgery, this is a real bear. And what I would hope is that the board just doesn't mess any more around with the silliness about it. It's not a matter of money. Every single doctor out there and every single hospital out there is supposed to be watching quality anyway. They don't need more money to watch quality. And all they have to do is report it. The question is whether you're willing to do it. That was not a question, Kevin. That's kind of a rant. I'm done. Thanks, Sam, because I was prepared to answer your rant, but since it was just a rant, I won't. I do disagree slightly though, him as you might suspect that I think. How do you disagree, how, Kev? Well, you talked about, you made a statement that a hospital might back out because they're being looked at on quality. And I would say, boy, I would not want to be the CEO of the hospital that espouses that they're backing out of this program because they're not meeting quality standards because that's disgraceful. So. How did you interpret what Sarah Barry had today? I didn't say that. Sarah Barry said it. Well, you repeated it. Well, I know, but I mean. You referred it specifically to quality measures. I think Sarah's was a little bit broader in that what she said, if is if it doesn't make sense. And I don't want to paraphrase what she said, but if it doesn't make sense for the providers, they're not going to participate, but I don't think that her statement was directly linked to quality, but maybe I'm wrong. Kevin, I asked Sarah Barry five years ago what the revision surgery numbers were. He said she had him and I've never been able to get him. The problem is it's too embarrassing. Kevin, I mean, if somebody was if somebody, if you had to get up every day and somebody was looking right over your shoulder and every time your dog barked when it shouldn't, then you just got dumped on. That is hard. That's a hard. That's a hard thing. It's very hard for medical professionals to do this. And if you think they're doing it somewhere, you tell me where it's being done. It's being done. I'll tell you where nowhere. Name one place. I think you're right there that it would change practices if a light was shown on quality scores for one provider versus another. You, it's super hard. I mean, it's painful. And I'm not saying I know how to do it. I'm just saying. Until you do that, until somebody can make a direct connection between what's going on in their environment and what they do until you can make that connection direct, then nothing will happen. It's because people exchange, change is painful and people only change if they have to. Okay, next I'm going to turn to Dr. Dean French. Thank you, Chairman Mullen. I thought it would be ironic for a hospital CEO and physician to follow him. You guys need a little humor. Actually, I had a real thought and I don't, I just think as we think about all these things and they're incredibly challenging, but in the front of primary care, it's interesting when you look at Vermont, we actually have a richness of primary care that's the envy of most of the rest of the country. In other words, we have a lot of primary care doctors and providers per capita compared to most other places in the country and the pipeline is fairly robust. What I would note is as we've pushed to try to improve value and improve care coordination and to Ham's point, measure a lot of process change. What we've seen is that provider panels have shrunk. When I was a practicing family physician in the late 90s, I had 25 to 3000 patients in my provider panel. The typical primary care provider in Vermont these days has, you know, 1200 is considered a very large panel and in my health service area, I'm seeing panel sizes of 8, 900. And so effectively, we've cut the number of primary care providers or access points in half because our panel sizes have decreased so much and you could argue they've decreased because we're spending so much more time on all the things that we think are important to prevent emergency room visits, et cetera. And at the same time, then patients can't get in to see primary care. They can't establish primary care. And of course, the ultimate dumping ground for patients who can't get in is the one place that's door is always open and there's no filter and that's the emergency department where we find ourselves doing more and more complex care coordination through the emergency department than ever before. And I don't have any answers to any of that. Other than I think it's important that we recognize that it exists and as we try to push the quality dime forward, what are we actually doing in the primary care space that's actually decreasing access and how do we remedy that? And so I'll stop there, but I just listening to this conversation which I think is incredibly important. And just for him, I would say that as a CEO of a hospital, the last thing I want to see is orthopedic revisions because I lose money on every single one of them. Anyway, thank you and have a good afternoon folks. Thanks, Dr. French. And I don't think Ham's going to let you have the last word because I see his hand is raised again. So, Ham. Thank you. And I appreciate Dr. French's comments. When I'm just for myself, I think the problem is not really primary care. I actually, one of the problems I'm working on and I have no idea how to do is to figure out how to get the check quality in primary care, but it's only 5% of the cost. The real problems, the real difficult problems are not primary, it's not that they don't need quality. I don't know how to do it, is much clearer when you get to hospitals and that are doing stuff like very complex surgeries. If that can be, we know that can be done. And if you want to change, that's 95% of the cost, not 5%. So, I appreciate Dr. French's comments. And I don't really disagree with them. I mean, the reality is that primary, I don't know how, I don't have a clue how to judge primary care quality. And I talk to a ton of people and I don't find anybody else that does. But surgery, big surgeries, orthopedics and stuff like that, that is ripe for to make, start to get to a point where you can go to revision surgeries. Revision surgeries is a question in Vermont. If the return to the OR is a big issue mass general Brigham in Mayo Clinic, Mount Sinai in New York, huge places. But in Vermont, once you've had a bad result in one place, you're not going back there. No Vermont design. And so the question is, there's some stuff you could do right today. Revision surgeries, think about it. Thanks, Sam. Next I'm going to turn to Robert Hoffman. Hi, thank you, Chairman. I just wanted to applaud the board's recommendations. If you look at the most recent data on the top 10 ACOs, they're having no problem funding their quality investments because they're making tens of millions in shared savings. Moreover, they can point to how they generate those savings. They can give you hard data that demonstrates it. This ACO has not been able to do that year after year when asked by both your board, as well as the healthcare advocate, how do they do what they do? They always keep it high level because they're not capable of giving you that information. I also want to applaud the resiliency demonstrated member lunge in pushing back and saying that not only must the value-based incentive fund be funded, but that it's not going to be taken from another quality investment. These folks, the roughly $1.4 million you're asking them to stretch equates to the additional salaries they're taking for employees to do the last work. Moreover, it roughly equates to the premium they're paid over the national median salaries for VP director and manager level hospital workers. It's nice to see you all finally demonstrating a little bit of grit and pushing back. That you all just have the resolve to follow through and do it. Thank you. Hey, is there other public comment? Is there other public comment? And it looks like there's no action to be taken today. So with that, I want to thank Marissa and Michelle for the presentation. And as I see it, the next item on the agenda is old business. Is there any old business to come before the board? Hearing and seeing none, is there any new business to come before the board? Hearing and seeing none, is there a motion to adjourn? For a minute, I didn't think anybody wanted to leave. We had three moves, but I'll take one of those as a second. And the motion is to adjourn. All those in favor signify by saying aye. Any opposed, signify by saying nay. Let the record show that the motion passed unanimously. Thank you, everyone. Have a great rest of the day.