 Good afternoon and welcome to the Green Mountain Care Board. My name is Kevin Mullinger of the Board and I'll call this meeting to order. The first item on the agenda is the Executive Director's Report and I'll call on Susan Barrett. Susan. Thank you Mr. Chair, welcome everybody. A couple of public comment periods that I wanna remind folks about that are open right now. We currently have an open public comment period on the State of Vermont Health Information Exchange strategic plan, as well as connectivity criteria. We heard a presentation on that plan last week and the public comment is open through November 25th. We also have a public comment period of the One Care Vermont ACO's FY22 budget submission and certification and that public comment period is open until, excuse me, December 1 to be considered ahead of the Green Mountain Care Board staff presentation on December 8th or by December 17th to be considered ahead of a potential Green Mountain Care Board vote, which is tentatively scheduled for December 22nd. And just as a reminder, we do not meet this Wednesday and I just wanted to wish everyone a happy Thanksgiving this week. And also that our schedule for a board meeting for next month for the month of December will be posted later on this week, likely on Wednesday. And that is all I have to report. I can turn it back to Chair Mellon. Thank you, Susan. Next item on the agenda are the minutes of Wednesday, 1117. Is there a motion? I move. Second. It's been moved and seconded to approve the minutes of Wednesday, 1117 without any additions, deletions or corrections. Is there any discussion? Hearing none, all those in favor of the motion, please signify by saying aye. Aye. Aye. Those opposed, signify by saying nay. Let the record show it was a unanimous but quiet vote. So at this point, we're gonna turn to the discussion to the 2021 ACO financial settlement and quality performance and to tee everything up and to introduce the panelists for today. I'm gonna turn it over to Michelle Degree and Sarah Kensler. Thank you, Chair Mellon. I will share my slides in just a moment, but what I'll do is likely ask each of the presenters to just introduce themselves at the start of their slide deck. I think that would be the easiest way to kind of go through this. So it's one deck altogether, but we've got pretty nice transitions in there if I do say so myself. So we'll be able to kind of have everyone introduce themselves as their payer program comes up into rotation. I will just note, I hope that this year we may get through, if you may recall, last year we broke teams and the board meeting never ended for about a week. So let's see how we do this year. I'm gonna share my screen and if you could all just let me know when you're giving me a thumbs up or something, if you're able to see it. We can see it. Okay, awesome. I'm gonna turn off my camera. So thank you. And again, today I will just make one correction to what you stated, Chair Mellon. This is the 2020 financial settlement and quality performance, not 2021. So today we're talking about the results for the ACO's Payer Program contract in 2020. And again, as stated, I'm joined by representatives of Medicaid MVP and Blue Cross Blue Shield who will again introduce themselves sort of at the beginning of their slides. As in years past, Sarah Lindberg and myself will represent Medicare during the discussion today. So quick agenda, we'll go through a few background slides that I have for you and then we'll go right into the results. And then we'll turn it over to the board for questions and public comments. So again, just a couple of reminders. Today's review of 2020 performance, although we are actively reviewing the 2022 proposed budget, always in a couple of different years here. So today's kind of discussion is relative to the board's ACO oversight authority. The quality performance discussed today is a reflection of the ACO's performance relative to its payer contracts and does not necessarily reflect the ACO's contribution to the state's performance within the all payer ACO model agreement. So for the purposes of agreement reporting, the 2020 quality report for those 22 measures specified in the agreement is anticipated to be released early in 2020. Just as another reminder, claims based measurement does take time. We're currently waiting for some final run out to be able to start running several of the measures required for the purposes of the agreement. And just another highlight that today is not an evaluation of the all payer model itself. To evaluate the APM, again, we produce those annual financial and quality reports. And the NORC has done some work and presented to the board already and we'll continue to do so. I believe the next report isn't for another couple of years, but that is something that's still on deck for them. Just another couple of reminders. Under the agreement, the ACO is a legal organization of healthcare providers that agrees to be accountable for the quality cost and overall care of beneficiaries assigned to it. The ACO's scale target qualifying programs must reasonably align in their designs across payers, which includes the ACO payer quality measures. So these measures, while certainly related, are separate and distinct from the state's performance under the all payer model. And everyone's favorite. So here's what we're looking at in 2020. The alignment here, so of course we have the APM is the first column there, and I know this is probably kind of small. It's getting harder and harder to fit on one slide. And then across each of the participating payer, so you have the all payer model measures first, then you have the Medicaid next generation program, the Medicare initiative Blue Cross, and MVP. Some measures, just to note, specifically initiation and engagement measure, we report separately for the purposes of the model, but our commercial payers do combine those into one rate, as acceptable by HEDIS reporting. It's just something that we do separately for the purposes of the model. Our program comparison, I always just like to make this note. So there's many similarities realized across the programs, especially beginning in 2019, given the ability that the state had to recommend design changes to the Medicare initiative in that year. As you'll recall throughout 2018, the GMCB One Care and the HCA had an extensive process where we negotiated which measures we'd like to see in the Medicare participation agreement. And so per the agreement language, those measures for 2019 to 2022 are in sort of more direct alignment with other ACO payer programs in operation. The differences that do remain are primarily due to types of covered lives. So for a pretty straightforward example, adolescent measures for commercial and Medicaid, but not for Medicare just makes sense based on their covered population. Couple of considerations I just wanna highlight before we get into the individual payers. While we do now have three points in time, comparability is still a challenge given several factors. So I've kind of highlighted these out for you. So in performance year one, 2018, the Medicare program followed the shared savings program, quality metrics specifically. So that is a little harder to compare to the next few years. So in performance year two, the Medicare program changed again for those negotiations. And there was the introduction of the Medicaid expanded attribution cohort. In performance year three, of course we had COVID-19, the public health emergency, which I believe every payer will touch on today. We had the introduction of the MVP program and we had further expansion in that Medicaid program. Another thing just to highlight is scale growth, right? So from 2018 to 2020, I've laid out sort of the attributed lives there for you and this is how we present it for our scale report. So Medicaid and Medicare are direct from prospective attribution. The commercial is as of January one of that year, just to sort of show you that growth. So I did some quick math just before because I thought somebody might ask me for percent change. So from 2018 to 2020, we saw 164% growth in the Medicaid program, 46% in the Medicare program and 105% in the commercial program. So with that, I'm actually gonna start by turning it over to Sarah Lindberg for discussion on Medicare financial settlement and then I will discuss quality before we turn it over to the rest of the panel. Sarah, are you here? I just don't see you on my screen. I'm here, thank you. Yep, there you go. All right, so we'll start here by talking about individuals. So the way that the Medicare ACO program is set up is that there are a set of people who are prospectively aligned and they might a-trit off the ACO program during the course of the year because they either don't retain both parts A and B of their coverage or they sign up for Medicare Advantage or they end up receiving the majority of their care outside of the ACO's service area for their primary care. So as you can see, the number of beneficiaries included at the time of settlement is lower than the prospectively aligned population and the difference there was bigger in 2020 than it was in the previous year and that's almost entirely due to the increasing take up of Medicare Advantage. So as the Medicare Advantage penetration rate increases, those still in the Medicare fee for service, traditional Medicare decreases. And so as soon as they sign up for that program, they are taken off the roster for the year. We also include people who do die along the way as long as they were eligible up until the point they passed away. So going to the next slide please, you can see the financial settlement in 2020, sorry for the small font, but essentially the large block up there is what the prospective benchmark initially was set at and then we have the benchmark as it was updated at the time of settlement. Due to the public health emergency, we ended up using a retrospective trend factor. You might have a vague memory of me coming before you in the early or late spring about that change, but we decided because there was so much uncertainty that we should actually use a retrospective trend factor, which means that this prospective benchmark wasn't actually finalized until about July of this year. And that was kind of a nod to the unprecedented uncertainty that we dealt with this year. So on a per member per month basis, the ACO lives were $700. And as you can see that's broken up into the aged and disabled, that's what A&D stands for, and an ESRD or end stage renal disease population. So again, not a lot of people in that ESRD group, but they have a much more substantial per member per month cost. So the quality adjustment could have gone down by up to $1.9 million, but the ACO reported all the measures it was required to. And so there was no quality withhold for 2020, which bet that their gross savings and loss was just over $27 million. However, the savings and loss is capped at a 5% corridor. So the maximum savings possible was $20.4 million. And so after you take 80% of that, which is the risk mechanism that the ACO selected within that 5% corridor, they ended up with a total net savings of $16.3 million. However, if you look back at line four or line two, you can see that 8.4 million of that was advanced to help with cashflow for funding the blueprint for health and SASH programs. So the net check to the ACO at the end of the year was $7.9 million. So if you wanna go to the next slide, please. So financial performance, this is just looking at the actual care. We're taking the blueprint advance savings out of the equation and just looking at what the performance target was compared with the ACO expenditures. So in 2018, they were $13.9 million below the target. So that's what they saved. They were a little bit over their target in 2019. So the 2.4 was over their performance target. And it's hard to call 2020 performance, but what happened in 2020 was that they again, had that $27 million below the expected target. And so Michelle, here's where we get into all the fun math of settlement. So each year shows what the gross savings or loss was, applies a cap to that on the second line. And then you can see which is the maximum allowable between those two lines. So if the savings is under the cap, it's the first row. If the savings is above the cap, it's the second row. You can see the quality adjustments there. So 2018 was another just reporting year. So there was no quality deduction that year, but in 2019, there was just under $200,000 deducted for quality. Below that is that risk arrangement within the corridor selected by the ACO, which is how we get to our adjusted cap savings or loss. We also had a little bit of weirdness that happened in 2018 because the sequestration that Medicare required at the time was not applied prospectively. So it had to be added at settlement. And then finally we see the advanced shared savings that again is for cash flow to help fund the blueprint and the SASH programs. And then we get the net settlement after we adjust for the advanced savings each year. So in 2018, it was a check in favor of the ACO for 6.2 million. In 2019, it was 4.9 million. And again, this year it was 3.9 million. So I think that was what I had to present for you today. So I'll send it back over to Michelle. Thanks Sarah. So we'll turn now into 2020 quality performance for the Medicare program. So as in years past, so just like 2019, there are four domains. There's patient caregiver experience, care coordination and patient safety, preventive health and the at risk population. I've listed here sort of the possible points, but again, due to the public health emergency, all measures were reverted to paper reporting in 2020, which resulted in a 100% score for one care per month. This I would like to just note is not specific to one care. This was a national decision. All ACOs were in the same boat. Specifically for the first domain there, you'll see that the CAP surveys, so the ones for ACO specifically were not collected at all in 2020 due to the COVID-19 public health emergency. Again, so some more considerations. We did calculate the ACO score using the pre COVID points rubric based on the raw score for each measure using this rubric. The ACO would have scored a 96.25%. So again, CAP surveys not administered. So we left that score at 100% for performance year 2020. And a really big one, the care coordination and patient safety score reflects the score for two claims based measures that are related to readmission. They're listed there for you. So ACO eight risk standardized all condition readmission and ACO 38, which is all cause unplanned admissions for patients with multiple chronic conditions. The ACO performs significantly better on these measures in performance year 2020 than in previous years. It's hypothesized the increase in performance is due to the changes made to the methodology. Because of these concerns, it's, so it says we do not feel, but Lewin who's CMMI's federal contractor and the GMCB have had conversations around this. So whoops. Oh boy. There we go. Yeah. Because of these concerns, we don't feel comparing the results to previous years is valid. So you will see that on the next in a couple of slides. I have not made that comparison. You certainly could go back and look at prior years, but it is sort of against what we would suggest doing in this case. And just as an FYI in performance year 2020, this is sort of thinking a little bit forward thinking for some of the other measures that we'll look at for the purposes of the all pair model reporting. There were a lot of methodological changes at the national level this past year. So we'll, this is sort of a recurring theme just to give you a primer for something you might see coming in the future. So again, a review of past performance, performance year one 2018, 82.4% paper reporting only the ACO did earn a 100% score. Again, that was the shared savings program measure set which had significantly more measures than the performance year two and three performance year two 2019, the ACO scored 91.88% and then performance year three again, 96.25, but a 100% score was earned by the ACO. With that, here are the 2020 Medicare result. Where applicable, I've included the 2019 rate. So again, for those first two, as I discussed with those methodological changes, I've not included it on this slide. And you can see across the board, you know, the increases were realized in some influenza immunization, follow up after discharge for alcohol or other drug abuse, and then initiation of alcohol and drug dependence treatment. There are some dropped here between the two rates. However, I will say that if you do a comparison and I can walk through some of these, if there are questions, but some of the denominators or utilization in some of these were significantly different between the two performance years. So something to keep in mind as we're looking sort of through this. And with that, I'm going to turn it over to Medicaid. So I believe I have Amy Coonrat and Alicia Cooper, who I will ask to introduce themselves and just let me know when you'd like me to advance your slide. Okay. Thank you, Michelle. Hi. Good afternoon. I'm Amy Coonrat. I'm the director of operations for ACO programs with the Department of Vermont Health Access. I'm also joined by my colleague Alicia Cooper, who is the director of managed care operations at the Department of Vermont Health Access. And we will be walking through the VMNG programs 2020 performance. Next slide, please. To begin with, we thought it would be helpful to frame the VMNG program in the context of Diva's priorities as a payer. There are three priority areas on this slide that the department has. One is related to value based payment of which this model is a keystone and another is related to performance. And by implementing the VMNG program, we are able to focus on Medicaid being a predictable and reliable payer partner and are able to focus on continual and incremental programmatic improvements as we make changes to the program year over year. And additionally, the program gives us opportunities to align with other similar payer programs and to be an innovative leader and come up with some ideas that other payer programs might want to align with in future. Next slide, please. The VMNG contract was originally, if you recall, for a one year agreement in 2017 with four optional one year extensions. Diva and the ACO one care have executed one year extensions for 2018 through 2021. Because the population of attributed members changes a little bit year over year, rates for the program are renegotiated annually and reconciliation for the program occurs annually, but it could occur more frequently than that. Because the VMNG contract, the original one is set to expire at the end of the 2021 performance year. In the spring of 2021, Diva put together and issued an RFP to continue contracting for ACO services for a 2022 performance year. And one care Vermont was the apparently successful fitter in this process. Currently, Diva and one care are actively in negotiations for a one year contract with three optional one year extensions with an anticipated start date of January 1st, 2022. Thanks. Before we go ahead and summarize the program's performance for 2020, we wanted to provide a summary of adjustments made to the VMNG contract to account for the impacts of COVID-19 during the 2020 performance year. As we have all seen the COVID-19 pandemic and associated public health emergency impacted Vermont's healthcare system significantly. And this also includes impacting the ACO's financial and quality performance in the VMNG program. As Michelle noted, in alignment with adjustments made to ACO programs at the federal level, Diva modified certain of its contractual provisions to hold providers harmless or COVID-19 related impacts on cost, quality and utilization during the 2020 performance year. These adjustments included making 2020 a pay for reporting year on the VMNG quality measure set. Decreasing the downside of the risk corridor proportionally to the proportion of months in 2020 that were in an active federal public health emergency. And since the federal public health emergency was declared in January of 2021, it resulted in a downside risk corridor reduction to 0% since there was an active public health emergency in all 12 months of 2020. It also included removing COVID-19 episodes of care from the calculations of ACO's total cost of care since the rates for the expected total cost of care for 2020 were developed using 2019 experience and therefore did not include, I'm sorry, using 2018 experience and therefore did not include COVID-19 related spend. And we will now move into the VMNG 2020 financial and quality performance. This slide shows the size of the VMNG program for each of its performance years 2017 through going to be 2022. In 2017 through 2020, the VMNG program saw an increase in participation year over year in terms of the numbers of communities and providers participating and therefore also an increase in attribution as a result of that. 2020 was also the first year that Diva implemented an expanded attribution methodology, which in addition to the members who were attributed by nature of their relationship to a PCP, the participating in one care Vermont, we would attribute members who are eligible for Medicaid don't have another form of insurance and don't have a relationship with a PCP that's not participating in one care. So that's our expanded cohort. Okay, something funky happened there, sorry about that. So after that, we see that provider and community participation and therefore attribution have remained pretty stable between the 2020 performance year and what will be the 2022 performance year. Just as a note attribution for the 2022 performance year was set on November 1st of this year. So there are those numbers for the 2022 performance year, which were debuting for the first time. I'll now turn it over to Alicia Cooper to discuss some of the financial results in more detail. Thank you. The next slide. So I'm sure this slide will look familiar to folks who have seen our presentation on the subject in prior years, just as a brief refresher, Diva and one care set and agreed upon price for each contract here of the Vermont Medicaid Next Generation ACO program. And we structure our risk arrangement around that agreed upon price. Just so that we have kind of an orientation to everything that we'll be looking at in the graphics that follow, I'll briefly walk through what's here. We can see that the green bar represents 100% of the total agreed upon price and the blue line is equivalent to that 100%. We then set a risk corridor around 100%. And in this example, we're using a plus or plus or minus 4% risk corridor, as indicated by the dashed red and green lines. And you can see that we have sort of a corresponding explanation for each scenario of performance around this risk corridor. If the ACO's financial performance is within the risk corridor but above the agreed upon price, so in this instance between 100 and 104%, the ACO network bears full accountability for financial performance within that range. This is creating an incentive for the providers that are participating to moderate costs and stay as close as possible to that agreed upon price. If the actual cost of care is beyond 104% of that agreed upon price or outside the risk corridor, DEVA will again bear full accountability for this financial performance. This protects against anything catastrophic happening during the year and allows providers to start changing the way that they're delivering care without fear of significant financial loss from the risk arrangement. On the flip side, if we think about within the risk corridor but below 100% of the agreed upon price, between 96% and 100%, the ACO network of providers is entitled to retain the entire difference. This creates an incentive to be efficient within the risk corridor and the total agreed upon price. And then if performance is below the risk corridor, below 96% threshold in this scenario, the remaining portion that is below the risk corridor accrues to DEVA in terms of dollars not spent on health care services. And this creates an incentive to continue spending money on care and not to ration services within the risk construct. So with that to frame our understanding, we can go to the next slide. At a high level, we looked at financial performance for two separate cohorts of attributed Medicaid members in 2020. As Amy mentioned, 2020 was our first year implementing our broader expanded attribution methodology. And so we had one cohort of members that was consistent with how we have looked at attribution historically, 2017 through present. And then the new cohort of attributed members that we call the expanded attribution cohort for which we looked at financial performance separately. The reason that we separated them out was because by definition many of these members have fewer claims historically that we can use to make informed decisions about setting that agreed upon price. And we had less certainty about what their actual utilization might look like during the performance year. So the risk corridor was more narrow for that new attribution cohort. So we'll show the results graphically for the two as we go further on. But overall, spending for the traditionally attributed cohort was approximately 11.6 million dollars less than expected on a total cost of care of 260 million for that group. And approximately 5.2 million dollars less than expected for the expanded attribution cohort where the expected total cost of care was approximately 61 million. One care, as I mentioned, is entitled to the full amount of funding below the agreed upon price and within the risk corridors. So when we look at this financial performance and we apply other necessary adjustments as part of our reconciliation calculations, DEVA will issue a reconciliation payment of approximately 15.4 million to one care for the combined performance in those two cohorts. Next slide, please. And here we have the same results presented more graphically. Again, this should look somewhat familiar as we have tried to use this format to share the financial results in prior years. On the left side of the figure, you can see the performance for the traditional attribution cohort. To orient folks to this particular graphic, we have the portion of the spending that was paid prospectively illustrated in yellow and the portion that was paid on a fee-for-service basis illustrated in that orange color. And then the gray block represents the spending underneath the agreed upon price. As we saw in the earlier graphic, the red, green, and blue bars indicate the actual agreed upon price and then the risk corridor around it. Amy noted on her portion of the presentation that because of the COVID-19 provisions in our contract, the downside risk in the agreement was eliminated. So the red dashed line here is more illustrative of what was originally envisioned but there was technically no risk above 100% of the agreed upon price after incorporating those adjustments to our contract. And that's noted with the asterisk at the bottom of the slide. So we can see for both of the cohorts we had the green dashed line representing that lower bound of the risk corridor within the gray section of dollars that underneath the agreed upon price. That means that the financial performance for both of these cohorts was below the risk corridor. So OneCare is entitled to retain for both of these cohorts essentially the difference between the blue line and the green dashed line. You can see that just visually the cost of care for the expanded attribution cohort was quite a bit smaller and the risk corridor as I mentioned was narrower for this particular cohort because of some of those additional uncertainties and how we would approach the rate development process. But other than that the mechanics worked the same for the expanded attribution cohort as they did for the general cohort when thinking about the comparison of the expected and the actual total cost of care. Next slide please. This slide is the same construct as we just looked at but showing our year over year performance since 2017. As Amy mentioned we've had growth in the size of our attributed population year over year since the beginning of our program and really you can think of those last two columns together as the full population for 2020. So quite a bit more growth beyond what we had in 2019 by introducing the expanded attribution methodology. And this is more just for a visual reference so that you can see year over year how the financial performance has compared to the risk corridors that we have established for the agreement. Next slide please. We wanted to take a moment to reinforce what we think of as the important role of the prospective payments in the Vermont Medicaid Next Generation ACO program in creating stability during the COVID-19 public health emergency. As we observed across the system there were significant decreases in utilization of health care services during 2020 particularly during the period of system shutdown but also as services were slower to resume once the system reopened. As providers were seeing revenue decrease for elective visits and procedures during the pandemic providers who were receiving fixed prospective payments as part of the VMNG program were better able to withstand the loss of fee-for-service revenue from non-Medicaid lines of business. And we think that this really underscores the importance of revenue predictability for providers as Vermont looks at increasing participation in this type of population-based payment model. We'll also note that the Vermont Medicaid Next Gen reconciliation payments that will be going to OneCare for the 2020 performance year will allow for additional resources to be directed to the health care system as the COVID-19 related pressures continue. We're not in that active period of system shutdown anymore but we know that the effects of COVID-19 are certainly lingering as we think about challenges relating to cases currently and staffing difficulties and so we think that this additional element of the reconciliation process is also an important part of the COVID-19 response from the Medicaid perspective. Next slide please. Here I'll turn it back over to Amy. Thanks, Alicia. So here on this slide which is also difficult to read as our quality measurement slides seem to be always here is the quality measure performance for the VMNG program in 2020. The columns that look orangey or yellowy are the rates and the numerators and denominators for that traditional attribution cohort and the greenish columns are the numerators, denominators and rates for that expanded attribution cohort and we also have included the 2019 rate for reference which is I think comparable only to the traditional attribution cohort. As we mentioned it was reporting year only for 2020 so the maximum number of points that the ACO could have gotten 20 they have received. This was done in order to hold the providers harmless for the impacts of COVID-19 on utilization. Reporting for the expanded attribution cohort was for claims-based measures only since some of the clinical measures required chart polls at providers offices and the expanded attribution doesn't necessarily have a relationship with the primary care provider so it would have been difficult to try and produce a hybrid measure sample for that population so the expanded attribution cohort only has results for claims-based measures here. As we said the COVID-19 pandemic has pretty significantly impacted utilization and during 2020 it had a particular impact in decreasing outpatient utilization significantly for a portion of the year. The majority of the measures in the VMNG measure set here are process related measures usually done in an outpatient setting and so the performance for 2020 generally is impacted by the pandemic-related decrease in utilization. Rates decreased for the majority of the measures for the traditional attribution cohort between 2019 and 2020 as a result of this. As Michelle had said earlier I would also caution against comparing the 2019 and 2020 results both because the 2019 and 2020 traditional cohorts are slightly different. There is some overlap between 2019 and 2020 and also because of the pandemic I think that had a negative enough impact for comparisons between the two might not necessarily be that insightful. I'll also note that this was the first year that OneCare had an expanded attribution cohort which has a different historic set of utilization patterns if they had historic utilization at all some of the expanded attribution cohort might not have had historic utilization and might also not have had any or little utilization during the performance year as well. So performance and quality for this cohort is also likely to be different than performance for the traditional attribution cohort. And now I will turn it back over to Alicia to talk a little bit more about future direction. Thank you Amy. Including at this point in time our 2021 performance year Diva remains committed to testing the Vermont Medicaid Next Generation ACO model and a new contract as being negotiated presently will allow performance to continue into 2022. We look forward to working with OneCare and providers to restore risk sharing provisions to pre-COVID levels in subsequent performance periods. Diva is also interested in continuing to use this model to innovate. We think that we've made some important developments in our attribution methodology by introducing the expanded approach to attribution and we expect there will be continued opportunities to refine this as we learn more about the dynamics of the expanded attribution cohort in more normal years than 2020. We think there are also opportunities to consider additional types of provider organizations that could be paid prospectively in future years. And we look forward to exploring potential modifications to the rate development methodology to allow for better year over year predictability recognizing some of what we have seen in the future years of volatility and fee for service utilization from one program year to the next. And with that we will conclude our portion. Thank you. Thank you both. And next we have Blue Cross and I see Andrew just popped up on my screen so Andrew just let me know if you'd like me to advance your slides. Thanks Michelle. I think we can jump to the first content slide. I have not met before I'm Andrew Garland I'm the vice president of client relations and external affairs for Blue Cross to shield the Vermont. Been working on payment reform healthcare reform in one form or another since 2008 and I've been working on the on the all pair model since a few years before it went live. So I thought to begin with and I won't spend a tremendous amount of time on this but as a reference for everyone involved I just put up the list of principles that Blue Cross to shield the Vermont has considered and that we bring to the table anytime we're thinking about this program and how to evaluate both the structure and the performance. This is our checklist for what is really important to our members and rate payers and I won't go down through the whole list now and inventory them but suffice it to say that the structure of our model with one care is really hitting green on pretty much all of these principles and what remains for us to prove out as we work together is that we can really generate results from that structure but in principle we're doing really well. So let's jump to the next slide Michelle and I'll talk about some things that are going really well between Blue Cross and one care as we work together and some challenges for us. Michelle can you advance to the next slide please. It's on the next slide on my screen. It's on bright spots and challenges. Okay, mine did not update for some reason let me shift over I have my own version here. Yeah, so bright spots the first two bullets really to tell us that our teams are working very well together and there's a tremendous amount of work going on. We have folks on our clinical team quality team, actuarial team, analytics team all interfacing with one care what the one care team regularly and that that collaborative approach has really allowed us to continue to work well and be responsive in the face of COVID-19. We've made some pretty dramatic changes to our program to help our providers and the market respond and continue to have faith in this program as we work through the rest of the pandemic and that really is born out of that collaboration. As some of you may know we have a hospital fixed perspective payment pilot it's not nearly as broad in scale as Medicaid it's more than a year into that and we've learned quite a lot about the operations in particular what it takes to make that kind of payment work in a claims processing system that was really designed for a fee for service so that's been really positive. I mentioned this last year we were just rounding it out as we got together for this talk last year but we worked together to pilot an entirely new approach to quality measurement for 2021 that's based on a work plan instead of a scorecard and I'll talk a little bit more about that later in the presentation but I think that was extremely successful experiment so far and we're going to learn a lot from that as well and then finally going all the way back to the beginning you saw that large uptick in membership on the commercial line 2020 I know quite a bit of that is the MBT program coming online but I would guess that nearly have also coming from some ASO clients on the Blue Cross book that officially joined the program in 2020 so we now have the majority of our ASO book fully participating in this program and that's great. On the challenges side I think we have two or three big challenges COVID-19 obviously has disrupted our ability to meaningfully measure quality or financial our results are sort of as far off from what we would have predicted as you saw from both Medicare and Medicaid our new quality work plan approach I think is a very exciting experiment I'm feeling very good about it it's still a little early for us to report out on that effort and I would just say across the entire program you know the one thing we're still looking for both on the quality side and the financial side is that strong connection between one care's work and the outcomes that we're seeing you know we've yet to be able to demonstrate a really strong correlation between the financial performance the quality performance and one care's work so we'll continue to work on that I think that's really the most important thing we can do in this program so we can go to the next slide Michelle next content slide financial outcomes and just let me know if it's up okay so those on the Green Mountain Care Board will appreciate the second bullet here was penned by our Chief Actuary I think you'll recognize his voice there truly I think what's important to take away from this slide is that we we altered our risk program with one care dramatically for 2020 and also 2021 because of the pandemic we as I said earlier we didn't want the providers or the market to be bearing you know the challenge of this risk model through COVID-19 so we dramatically reduced those corridors and really we also saw this tremendous distortion of normal utilization patterns that started very early in the pandemic and the data we have from 2021 really tells us nothing about the one care program it's just so skewed by COVID-19 and we're sure that 2021 will be similar and at this point we're preparing for a 2022 that is still likely to be pretty significantly disrupted and I think our contracts will reflect that we can go ahead Michelle two slides to the impact of unquality in 2020 we've heard this from the other presenters our old scorecard was based on those benchmarks from CMS and NTQA we don't have those benchmarks for 2020 and we saw like what Amy presented just a few slides ago 2020 results that are just really hard to interpret the numbers are all over the place and they don't appear to be related at all to what one care has been working on we understand that COVID has diverted everybody's attention and disrupted the normal pattern of care so that those measures are very hard for us to report on and we really don't deduce anything from what occurred in 2020 I also just sort of note on this slide that this could be problematic for us for the next couple of years 2020 was to be our baseline for our large group population they're new to the program in 2020 so we don't have any history there with one care obviously this first year is going to be pretty distorted and it may take us a year to really understand what the baseline for that pool looks like and then finally for us as you heard from from Medicaid 2020 was reporting year only for us on the quality side in addition to changing the risk model we changed the scorecard model as well so that the providers would not be penalized for what we knew was going to be extreme disruption we can go to the next slide and then I did promise to talk a little bit about the quality improvement work plan so I'll land this presentation there and then we can certainly take questions if you have any but we you know as I mentioned and I may remember I reported about this in the past we see in the scorecard in 2018 and 2019 some bright spots some downspots but what we haven't been able to show in the past is consistency of cross measures across years so a measure that might seem like it's on a trend that we've moved in 2018 doesn't stay on that trend in 2019 and the other thing that we haven't been able to show in the past is where one-cares efforts were directly related to the outcomes that we were seeing on the quality program it honestly seemed a little bit random and when we compared the results of that scorecard to what was happening with the rest of our population or any clear indication that we could see one-cares performance in that scorecard so we decided to change that to do an experiment and really try to get focused on this so instead of having the broad base scorecard with what we had 10-12 measures in the original 2020 scorecard we're now moving to a work plan method that's focused currently on just two measures so what we asked one-care to do is to measure in a couple of measures that they were intending to work intensely to improve and for 2021, those are the measures shown in the middle of the slide here controlling blood pressure and having that screening for depression and substance use with the pediatric and teen population so those were areas they planned to work on so we just stepped away from the scorecard and said, okay, what does that work look like? What will you do throughout 2021 to make progress on these measures? Let's put that into an enumerated work plan and instead of scoring just on the outcome score we'll actually score on your work throughout the year to move these measures and then we'll have a lot more confidence when we get the results of the scoring on these measures in what we're actually seeing there try to demonstrate that your work on these measures can really move the needle so that's what we're focused on there I'm pretty excited that this is going to tell us a lot about how to structure a quality program that really ties the effort to the outcomes I think this is going to be a big deal for us and we're looking to expand this in 2022 we're already talking to one care about the potential to add a third metric to the work plan we would probably be targeting their mental health and substance use disorder support that's a place where I think as a system we're tending to lag behind our scores have not historically been very strong there and we know it's important to the entire system so it seems like a nice place for us to focus going forward so that's all I have to present I can take questions now or later if the board prefers Thank you I think we'll hold the questions to the end Okay Andrew And Carla, I see that you just popped up so I will turn it over to you You're on mute Carla Thank you I am Carla Renders from MBP I'm the leader of professional relations and value-based programs for Eastern New York and Vermont I also have some of my colleagues accompanying me here on the phone today so I'll let them introduce themselves as well Scott Hi everyone I'm Scott Monro Vice President of Network Strategy and Strategic Partnerships including New York and Vermont Matt Hi everyone, Matt Lombardo Senior Leader in the X-Rail Department I hope everyone's doing well And Katie Hi everyone, Katie Poole I oversee our quality measurement and improvement teams here at MBP Great, thank you So we can get started on the first slide Since this is our first time presenting to this group being it's our first year in the arrangement with One Careite we did want to start the presentation and outline MBP's mission which is to continue to improve our members' health and well-being through innovation and collaboration which we call to date both internally and in our arrangements with our partners such as One Care Our focus is always our members and everything we do and with them at the forefront we believe and we intend to create the healthiest communities We can advance to the next slide So how do we get there? How do we achieve our mission and our vision through our core values? We want to be the difference for our customers meaning our members and make them feel reassured that their health care needs will be met We are curious as to their wants and needs and work to anticipate those wants and needs and address them proactively for a better consumer experience and finally we are humble. Humility allows us to keep an open mind and be receptive to innovation and innovative ideas from all our constituents be they employees, members, providers or our business partners We can go to the next slide So moving on to details of our arrangement with One Care and the associated financial performance for 2020 So the overview of the program again this was our inaugural year of our arrangement with One Care so our presentation is going to be a bit shorter than the other since we don't have year over year to share It was a one-year contract it included commercial lives under qualified health plans meaning commercial individual and small group membership It's an upside only total cost of care shared savings arrangement with the amount of savings being subject to a minimum and maximum savings rate and also additionally a quality gate and we'll look at the quality component in the next section of the presentation The quality metrics used for the quality gate were metrics selected from the all-payer model and aligned with membership in the commercial lines of business As part of the arrangement MVP provides One Care with a data extract consisting of eligibility claims and financials for the attributed population on a monthly basis and additionally financial reporting on a monthly basis as well We also provide One Care with a primary care investment payment which is distributed to the downstream providers and we also had a care management payment available to One Care for members that One Care identified as high risk We can advance to the next slide So just to review some of our successes and opportunities our successes were due to a highly collaborative team at One Care and MVP that were together to get this program up and running the first year and we did meet all the actual timelines The program did result in savings for year one again it should be noted that this was an unprecedented year due to COVID I don't think I need to say it again all of the other presenters have alluded to that as well which caused utilization to plummet starting at the beginning of March which had a favorable implication on the budget There are also some opportunities that we're working on in our next iteration of the contracts such as enhanced alignment of reporting and analytics, ability to better identify and engage members needing care management and the selection of quality metrics that better reflect the MVP population and you'll see what I mean by that when we get to the quality scorecard we did have very low denominators in some of the metrics rendering them invalid So moving on to the next slide actual financial results So what we're looking at here is an illustration demonstrating how one care performed against the budget So the budget was established by looking at previous year meaning 2019 utilization and coming up with a per member per month dollar amount which was $420.36 per member As you can see in quarter one the actual spend was a bit over budget and then with the entrance of COVID in March you do see a large drop in utilization It should be noted too though that each quarter does show year to date spend so quarter two really means the period from January to June not March to June I'm sorry April to June Attribution for the program was a little over 9000 members and one care did achieve achieve savings coming under budget at a rate of $384.02 per month for savings of $36.34 per month by the end of 2020 Ultimately taking into account the minimum and maximum savings rate and the quality gate did result in a distribution of savings of $1,062,000 to one care and that was just communicated to one care about a week and a half ago so this isn't finalized yet with them but our contractual agreement was to get the final results mid November So we can advance to the next slide actually the next one to go into the quality program overview so again quality metrics were selected by one care using a selection from the all payer model 2019 CMS benchmarks were used the point system determines the amount of shared savings due to one care and the subsequent slide will show the score card that demonstrates how the points were distributed across measures score on the score card is what ultimately determines the amount of savings to one care it should be noted that three out of four of the measures had such low denominators some of them only had one or to four members that the points for those members were redistributed to the rest of the metrics the score card that you will see in the next slide was distributed to one care at the beginning of the second quarter of 21 and then it's finalized at the end of the year along with the financial settlement because of the nine months of claims run out required to settle the program the 2020 results contrast like I just stated were due to one care on 1115 we can advance to the next slide so this is the the score card with the results for 2020 this is the format that we distribute this to one care with each of the metrics selected for the program again the three highlighted metrics are the ones where there was such a low denominator that the points had to be redistributed so the 30 day follow-up after discharge from the ED the follow-up from ED for mental health and the follow-up after hospitalization I mean you can see there the denominators are either one or four members and then the key at the bottom of the score card shows what percentage of the points are earned based on the percentile that one care reached for each measure according to the CMS benchmarks because the 90th percentile was reached for all cause readmissions and the diabetes measure a hundred percent of those points were earned while half of the points were earned for adolescent well care and zero points were earned for controlling high blood pressure and initiation and engagement of alcohol and other drug as they those two came in below the 50th percentile resulting in a total point distribution of 50 points keep in mind again that the low scores and the low denominators could obviously be impacted by the pandemic that concludes our presentation on the MVP side if there's any while you were waiting to then for questions I look forward to questions thank you thank you Carla with that I will turn it over to one care so I look like there there you are if you've prepared any comments please please feel free hi everybody my name is Josiah Mueller I am director of value based care here at one care Vermont it's truly an honor to be here representing one care background I'm a registered nurse with a clinical background and I just really excited about working in value based care here in Vermont good afternoon everybody Derek Rains I'm the director of payment reform for one care Vermont I have a legal background by training happy to be here working on this important work thanks for having me I'm uncertain if we have any other one care can't see the full list I'll just pause for a moment okay so I'll get started with just a couple of comments so first and foremost we just want to reiterate what we've heard today which is you know these are just extremely challenging times for our providers and we are you know we see our role as doing everything we can to support our providers during these challenging times one of the ways in which we're doing that related to this presentation today is you know so we have these multiple payer programs we identify our quality results over here it is November and we're talking about 2020 and so our providers came to us and said we'd really like to get more timely data to know how we're doing at a practice level at an organizational level as opposed to sort of you know months after their performance here without that granularity that really allows them to improve their operations to you know dial the right dials and improve their quality so this year in 2021 what we've done is we've created a system where we on a quarterly basis drill down the practice level organizational level excuse me and providing a sample of patients and that practices performance for that sample so and you know a little bit of data much more timely and our quality improvement specialist team is meeting with practices so that they can work through these results together and provide support as necessary second I think it's an important point to note is just you know obviously these are very difficult to interpret these results personally you know here at one care we're interested to see what these look like nationwide and you know can we really draw much conclusion from these I'm not convinced just yet I'm interested to see where are the ebbs and flows given the nature of COVID and how it did fluctuate in different populations throughout the past you know throughout the year year plus and then finally so here at one care when we work through these processes it's it's really about delivering these results to our internal groups and internal structures internal committees to talk about action plans and next steps and what can we do to improve and so that's you know in the coming months we will be working through these results with our committees and our governance structure to evaluate next steps and the best plan you know just a couple a couple comments briefly that I would add to that from the payment lands most things have already largely been covered by the provider the payer presentations but I would add that from a payment angle like Josiah said we've really just been trying to support our provider network so that largely came in the form of limiting downside risk with corridors and then also just making sure the fixed payments continue to operate as normal so that they could count on that revenue when utilization and other things were a little all over the map so that's all that's all I wanted to comment on today I look forward to be here to assist with any questions that anyone might have. Thank you both. With that Chair Mullin I'll turn it back to you for any board questions or public comment. Thank you so much Michelle I'm going to go in alphabetical order and call on the different board members to ask questions. So about your board member, Jessica. Great thank you that was a lot of helpful information from everybody the payers and one care really appreciate it I guess one of the things I'm taking away from this the clear trend here is that particularly with the quality data but also obviously with the financial data the pandemic has had a huge impact and when I think about how we're going to find comparable meaningful comparisons over time I'm even thinking going forward it's going to be challenging to do so compared to 2020 or even 2021 if there's on the quality side if there's changes in methodology that are happening certainly on the denominator side with the huge disruptions and utilization that we're seeing we're probably still continuing to see I guess I'm just wondering if anybody can speak to how we're going to ever make meaningful comparisons over time even in 2022 and 2023 looking back I guess I'm just thinking about that that's one of my big takeaways obviously it's a big takeaway for everybody what does the post COVID world look like but I'm thinking specifically about this evaluation of the performance here based on these pair contracts with these big disruptions I don't know if anybody can speak to that maybe there's just no answer but Any of the commercial or Medicaid on the line if you all have a response please feel free to chime in no need to hand raise or anything or one care and then just point out that is that we anticipate NORC doing another round of evaluations and I'm really curious to see how they handle this as well we might learn something from them in that aspect and how they choose to kind of address this this big shift that was the first kind of place my mind went was the fact that we are grateful that the NORC did their evaluation a gold standard evaluation was able to be completed prior to the pandemic and they found both our ACO compared to a comparative ACO and our state compared to a sample of patients to adequately represent a comparison group of folks they showed savings and they showed fewer hospital stays and shorter hospital stays and lower readmissions rates so it's a great question and I'm with you Michelle I'd love to see how they handle that it doesn't sound like I have any takers on that but I guess it's something we're going to have to work on going forward Andrew I'm wondering if you can speak a bit to you mentioned important learnings from the hospital fixed perspective payment pilot that you're doing and I know it's a small sample but I'm just wondering if you can speak a little bit to what those learnings are and some of the challenges that you see in scaling that program up to more hospitals yeah thanks yeah thanks we can if anybody who's not speaking could mute themselves it would be greatly appreciated are you able to hear me at all yes we can hear you loud and clear I guess the bigger question is can you hear us Andrew you might even be frozen are you there Andrew sounds like maybe he's dialing in and it looked like maybe Derek had something to add to the last talking point Jess I don't want to put you on the spot no that's fine thank you for that I was just going to briefly add that I think it's an iterative process that we're going to have to continue to work with the payers as well in going forward and collaborate with them to try to learn whatever we can as time goes on it was a small comment I didn't mean to interrupt the process maybe I'll just ask another quick follow up question to that I'm just wondering has anybody done an assessment of whether some of the quality measures which are process measures whether there's an equivalence and a telemedicine visit an in-person visit on some of those process measures I imagine it's more difficult for example to test blood pressure obviously on a telemedicine visit than an in-person visit so that metric would be problematic if we're seeing a shift towards telemedicine during the pandemic I'm just wondering if there's been any attempt to think through that on those quality metrics I know I'll just say from the GMCB staff perspective not necessarily process measure payer but from our perspective we are hoping to do an analysis on any uptake and telehealth utilization throughout 2020 and into 2021 so while not entirely getting at sort of that process that you're speaking about it's something that we wanted to make sure we had a clear understanding of so you'll see that when staff present our 2020 annual total cost of care results I believe so early next year Andrew are you back with us? I hope so can you hear me now? We can do you want to attempt to answer Board Member Holm's question? Yeah sure so the the learning I refer to is largely technical you know coercing a system that was designed to pay fee-for-service claims into a fixed perspective payment model and we had some stumbles with South-Western some of the mistakes that we made I think we're similar to mistakes we've heard about from other payers but I think we've ironed a huge amount of those out and we've also learned a lot about how to automate this processing so that we don't have quite as much spreadsheet going on spreadsheet going on as we had for the first few months of the program that we're currently enrolled in So just a quick follow-up question Anything you can speak to about sort of the hospital appetite for moving into a fixed perspective payment conversations you might have had with other hospitals and what their interest is in it and what you know what learnings at Southwestern has had I mean you can't speak for Southwestern here but pitching it to other hospitals is there any obvious obstacles or besides the technical? Yeah I think there are only two obstacles one the big one is COVID we just need to get this behind us we had very high hospital interest in this program across the stage six months before COVID hit while we were finalizing the project to bring the technology up to speed and there were a few other hiccups along the way you know the cybersecurity challenge I think that UVMHN has slowed them down very understandably but I think interest was pretty high so I'm not I'm expecting that once we get out of COVID kind of look towards at late 2022 we should be really well positioned to get back to where we were the only other remaining obstacle I can see is that we do have to come up with a new way of target setting if we're going to be successful in fixed perspective payment we've used essentially a retrospective risk adjustment in the past look at what actually happened and then help us score the risk of that population that's fine for a retrospective settlement approach where we're settling six months after the period is over but obviously to get to fixed perspective payment we're going to have to do something different there we're going to have to bring that risk adjustment up to the target setting at the beginning of the cycle so that we can make the appropriate payment that's a pretty big methodology change it's going to take a lot of mental crunching by all involved everybody's going to have to feel good about a new approach and I do think that will take some time and effort great well thank you that's really promising to hear that's all I have Kevin pass it along thanks Jess next we're going to turn to board member lunch Robin great thank you I did have actually a follow up on this topic for Andrew so my understanding of your current payment methodology is that it is reconciled to fee for service am I remembering that correctly yeah that's right and so when you when you mentioned moving the risk adjustment up to the front end are you thinking about that as part of what needs to happen to move that from a reconciled fee for service to a true fixed perspective payment or is that something that you're thinking needs to happen either way yeah no that's right in order to get to reconciled we've got to make that change absolutely great and then my other question about it was have you thought and I'm because of covert I wouldn't necessarily expect you to have been able to do this work with the hospitals but I'm wondering if you've had any thinking about sort of the critical access hospital incentives in a fixed perspective payment versus maybe other hospital types you know we have it it's a great question and it's something that I would expect we would work on together with one care you know I'm part of their mission is thinking about how to get the right financial assessment or incentive to the right places in their network to support the work they're trying to accomplish that's something we probably have to figure out together thank you so I also had a question for the folks from MVP welcome thank you for joining us it's great to have your report from your first year in the model I was curious since your program was a shared savings program if you've thought about moving that into at least a shared savings and risk program and or really what your planning or thinking is around moving towards fixed perspective payments so this is Scott Mamro board member lunch absolutely when we were in discussions back in 2019 with one care Vermont it was a glide path contemplation towards risk as everyone has discussed the impact of covid has certainly impacted that that glide path for a variety of reasons we're still as everyone is trying to understand the impact on quality measures member engagement related to population health and quality actuarial models I think Andrew Garland did an excellent job articulating the impact on the models and we're certainly working with our actuaries on how do you look at those targets moving forward as you move towards risk we've also heard from one care Vermont as well as individual participants obviously this is a challenging time to move towards downs because we still have a covid hangover happening as it relates to just volatile utilization and we're still trying to understand the patterns but that is the direction we're heading and we're also supportive of the move towards global capitation and the models that are consistent with the all pair model thank you yeah I mean covid I don't think we can say it too many times covid has really made it challenging in 2020-2021 and knock on wood I hope we come out of it in 2022 so that we're able to really refocus on our health reform goals as a state the only other this isn't really a question per se I'll just throw it out there is that knowing that many of the the results from 2020 the financial results are just coming out now in the past week or so I think one of the areas that we're going to need to look at when we come back to the one care budget is how that how the shared savings sort of fits into the budget as it was filed so I'll just make that as a note as an area of interest when we move back to the budget process but thank you all very much thank you robin next we'll turn to board member pellum Tom well thank you as I listen to this conversation it's obviously clear in an understatement that covid has been shot in everybody's side a negative shot but one positive thing I'm sensing is that this conversation is moving along and looking forward that here we have all the players around the table a lot of the terminology is well understood across the folks that are involved here some important infrastructure has been built in terms of relationships with one care and so I'm my sense is that process wise we have lost some time but the networking and interaction of the players has moved forward despite covid my first question is having to do with kind of the scale growth build out especially for Medicaid and Medicare I'm just wondering those have and I think it was slide 7 shows some tremendous growth rates there and I'm just wondering what would what are the expectations for a full build out in terms of scale growth for Medicaid and Medicare because relative to commercial commercial is still quite immature but we must be getting to a fairly mature build out in terms of the scale growth for Medicaid and Medicare and I'm wondering if we have a sense of what that additional margin might be sure so I'll start with just one statistic from our 2020 scale report which is we did a couple of additional analyses you might recall that we presented to the board and one of the really notable ones was that we were at about 90% penetration of provider participation in the state so that there's not a whole lot of extra margin there despite not meeting scale targets specific to Medicare and Medicaid I can ask Sarah Lindberg if there's anything she wants to point out about Medicare and perhaps out of state care and then I'll turn it to Alicia and Amy yeah I guess the way I think about it is you pick up people by more providers participating by having more payers participating which we're doing a very good job on and then from there kind of monkeying with the attribution algorithm if we're wedded to a prospective model so I think that we're in the land of diminishing returns there's certainly some geographic attribution models that Medicaid is bravely piloting that other programs may consider and they're also I think opportunities if other methodologies that also might help but I think with these current models we're kind of nearing saturation so just to follow on with that a little bit if we are nearing saturation in terms of Medicare and Medicaid attribution um you know and certainly we're nowhere near that having to do with the commercial folks I'm just wondering if Medicare if the you know the build out for example of fixed perspective payments for Medicaid which is pretty much in play and we are trying to get to get to that with Medicare and kind of current negotiations you know will that become a a kind of a comforting a source of information for the commercial folks to you know pick up the pace in their arena so that we can all be moving forward at a collegial collegial rate I would say because I do go back to the hospital budget process where I think it was the I have it here somewhere where the overall in terms of like true fixed perspective payments the overall rate for 2021 projected budget was 17% Medicare was at 41.8% Medicaid at 42% and commercial at less than 1% so I'm just kind of wondering is as we get to maturity with Medicare and Medicaid does that become a beacon hopefully you know for the commercial folks to feel that the risk might not be as bad as as they might fear now that's an observation my next question had to do with Medicare and I think I can answer this myself because of the retrospective nature of the benchmarks for 2020 but my question was as Vermont pushes forward with Medicare toward unreconciled FPPs do the settlement results for 2020 offer any insight on that discussion and my guess is not so much just because you know it was it was a the benchmark used a retrospective one as opposed to a current one would that be right Sarah yeah yeah I don't know that 2020 has a lot of precedent for us in a lot of ways okay so this one is for the Medicaid folks in negotiations between Diva and one care how was the cost shift factored in and so a specific example in my mind is that for 2021 Diva went to the legislature for the 2021 budget adjustment and made the statement I don't know if it ended up being the final result but that that they were not going to allow any reimbursement increases for 2021 other than those that were related to FQHC and so I'm just I'm asked so I would like to hear from the Medicaid folks how do you handle the cost shift in your negotiations as part of our rate development methodology we take into consideration any projected changes for the coming performance period in Medicaid reimbursements as you mentioned in 2021 we did not have any funds available in Diva's appropriation to support rate changes with the exception of those rate changes that are federally mandated including the updates that were implemented for federally qualified health centers to the extent we do have funds available for subsequent performance years that anticipated change in rate will be factored into the rate development process as part of our process and change of sanctions beyond that there isn't specific contemplation of a cost shift in the development of rates for contract negotiations so one takeaway for me from that is that let's assuming that all of this investment in health care reform is positive and it's yielding results and I just I've said this before but I just worry that the cost shift and as occurred unfolded again in 2021 I'm worried that the cost shift becomes out of the system in terms of the network kind of getting the benefit of any efficiencies that they might be finding in the system attributable to it so that's just a worry I have my next and final question was how given how is the appropriation process work for example with this set where was the quote here the quote was $15 million settlement right Diva will issue one care a reconciliation payment of approximately $15.4 million so that is that will be paid out by the state in the current fiscal year I assume but it's for something that occurred retrospectively so I'm just wondering how that gets manages how Diva manages that in the state budget process in so far as Diva and one care agree upon a price at the beginning of the performance year there is the expectation that the agreed upon price is going to work within Diva's overall appropriation to the extent there is any difference between what Diva has appropriated and its financial liability to one care at the close of a performance year that would be addressed through the budget adjustment process we believe that there may be some inclusion in the budget adjustment of contemplation for the reconciliation payment because of differences that were driven by the public health emergency and Diva's response to that in other programmatic areas including the additional caseload that Medicaid has been carrying for the last more than one year right that's all the the timing issues here got to be a little bit difficult to manage but thank you very much those are my questions thank you Tom so at this point I'm going to open it up for well I see Andrew you have your hand raised yeah thank you I just wanted to briefly offer some input on the question about commercials participating in the scale target just based on that that observation I think Blue Cross the Shield of Vermont is considerably north of 1% participating we're actually above 20% and actually I think the limiting factors now are generally beyond our control so you're aware we have individual small group large group insurance and ASO all participating so that's really all commercial segments we do have one large ASO client who is opted not to participate and that you know will continue until until they've seen I think some strong results from the program but other than that for us it's really provider participation that is limiting future attribution so unlike Medicaid we're not at 96% participation there's many providers who are participating with Medicaid or Medicare who have chosen not yet to participate on the commercial side and I think that's about stepping into that risk-taking arena incrementally so OneCare keeps a really great list on their website you can go out and take a look and see which practices are participating with which program I refer to it all the time as I'm talking with providers about this program but I think that's the big limiting factor for us at least that if we had the rest of the network participating our numbers would jump up considerably and then just the other observation I make is that there is at least one large national payer and a couple of smaller nationals in the state who don't participate at all on the commercial side and they're carrying a significant amount of membership here and there so just as we're accounting for everything that could be in that bucket I wanted to note those things as well Thanks Andrew so at this point I'm going to open it up for public comment and I'm going to remind anybody with public comment to address any of your comments to me as chair and so at this point you can either raise your hand or if you are just on the phone and not through teams you can just speak up is there any public comment at this time Julie Wasserman thank you chairman I have a couple of questions the first is related to Diva and its capitated payments to the hospitals for 2020 we all know that the hospitals got paid even though they did not provide the usual level of care in fact as one speaker said utilization had plummeted in 2020 capitated payments are touted as a great approach to incentivize providers to keep people healthy but that's not exactly what happened in 2020 because the providers were not seeing patients so they didn't have the opportunity to keep them healthy in fact we know that the providers were not keeping people healthy as evidenced by the pent up demand that we're seeing right now and also the late stage illnesses that we're also seeing so there's the capitated piece additionally there's the quality performance unfortunately the PowerPoint showed no slide on the Medicaid quality results but if you look pretty closely you can see that the ACO performed poorly in their Medicaid quality measures one care's performance worsened in 9 of the 10 measures compared to last year so basically the declines in performance were across the board 9 out of 10 measures so my question with regard to these issues is how do we explain Diva paying one care $15.4 million for less care and poor performance it's an interesting question I don't know if anybody from Diva has any comment but certainly we're working through a lot of those same questions Julie as we go through the budget process thank you I have another question let's give Alicia or Amy a chance to respond if they so desire oh sure Alicia do you wish to sure I think the one thing that we would reiterate is that we saw significant value in the prospective payment structure within our energy program in ensuring additional stability to the healthcare system during the period of system shut down and then as the system was returning to more normal rates of utilization whereas providers who were relying primarily on fee for service revenue had much more difficulty withstanding the effects of reduced utilization on their cash flow I think the prospective payments were important to ensure that our providers were able to stay open and continue to be responsive to the needs of Vermonters during this time even when those needs weren't strictly consistent with what we had seen historically. Now on the quality point I think speaks to the question that Board member Holmes was posing to the full group we know that 2020 was radically different from other years it will be difficult to compare performance in 2020 to either years prior or years that follow given how different it was in terms of what our system observed and that's something that we would have to work on as a collective and we'll have to see how nationally that is approached as well. Okay next I'm going to call on Ham Davis. Thank you Kevin this is sort of a half question comment. One of the difficulties I've seen in the whole presentation today that it's getting increasingly difficult to hook anything for something else the basic idea of shifting from service to capitation the whole sort of the centerpiece of the whole reform movement is to change the incentive to work on doctors that are actually delivering care in the system and more and more it seems to me it's very difficult I think there is something like 1800 to 2000 doctors in this state I can't believe that there's a single doctor that actually does any doctoring work which is hard and takes time and has the faintest idea what is going on with all this blizzard of back and you have a specific question for Andrew Garland one of the things that I think is that people keep talking about one care of Vermont one care of Vermont is just basically the hospitals and and one of the things that happens at least and it has I think not just now but has the last 50 years the money that the federal government and the state governments pay for Medicare and Medicare the number they choose but the people that are paying the people that are paying hospitals and doctors essentially are essentially the private sector and that's Blue Cross and MVP and so the people that know the most about what is money is going is Blue Cross and MVP I remember going back in the back 20 years ago that Blue Cross representative would go to Northwest and sit down with the CEO of the hospital and they'd just argue about it and Blue Cross would tell them what they were willing to pay and so the people that really know where all the money is going is Blue Cross they're the ones and MVP to the extent that they share in the market so my question would be my question would be and since I should get to a question here Kevin if you could ask Andrew Garland if he if Blue Cross has feels unhappy about some hospital way it behaves even in the quality area actually you know one care can't put on a bandaid if this problem with quality it's quality delivered by Vermont's hospitals and its doctors why can't Blue Cross get at that directly they're the ones that they really have the balance of power they're the ones that have the leverage with the hospitals not one care well it's a little bit outside of the scope of what we've asked Andrew to come talk to us about today but Andrew if you wish to answer go ahead yeah sure I guess I could give a really long answer the short one is that we're both working with one care Vermont and we continue to maintain strong collaborative relationship with the hospitals and providers across the system so we talk quality with one care and we ask them hey if you're if you're really organizing physician led change help us with these things let's figure out how we change the system change the payment to allow our providers to be more successful in these areas but at the same time we continue to work directly with providers we have contracts with all these providers that we negotiate directly and our quality improvement department has many many programs that continue to operate independently of the one care program and they probably will for the foreseeable future so you know just think of it as continuing to exist in two places and I think that will happen for a long time okay next I'm going to call on Walter Carpenter thanks Kevin Julie Wasserman kind of stole what I was going to say which was a good thing because she phrased it so nicely with the capitation payments I keep thinking of the wait times at UVM that have come out over in recent articles but I won't dwell so much on that now because she already mentioned it Ham made some good points too that I was thinking about but one thing is just more of a comment and throughout this presentation I've constantly listened to a word called the payers and to reiterate what is obviously the obvious that we all know is that we are the payers we the people we pay we pay the system the insurance companies are the middle the insurance companies diva etc are the middle people from which it flows through I just want to reiterate that because we are the ones that are going to be paying these bills thank you Walter next I'm going to call on Robert Hoffman thank you chair mullen I want to make a correction to ham he consistently describes this as just essentially a fiscal pass through it's not all the contracts state that there are to be institutional level rigorous programs around quality measures specific disease states and as blue cross blue shield enumerated there's really no evidence yet to date four or five years into this project to even in a corollary way demonstrate that improvement projects are having an impact on savings and quality moreover I would challenge the ACO to present the programs that they've done around disease states like diabetes how frequently are they pulling quality measures or are they just sampling for the quality score once annually that would be nice to see while the rest of the countries ACOs are using AMA programs like together to go for diabetes we really have no evidence blue cross can't certainly point to it how for what is being done to impact these measures I'll come in and I'll piggyback on that to make it more precise what's happened for 2020 is Medicare and Medicaid have decided to socialize the losses and privatize the gains they're happy to explain away any possibility of discerning what happened in the world of quality we're holding the ACO accountable for it it comes to quality measures and the ACO is clearly paid in part based on quality measures they're happy to dispense with that and then concurrently to pay out 23.3 million dollars combined when utilization as they acknowledge plummeted when insurers last year were giving money back to premium payers I think we should be asking why is the ACO not doing the same and if they're not going to do that where are they going to direct these savings other than back into the 62% holder of Vermont healthcare spending UVM Health Network so I would exhort the board as it continues deliberating over the budget process to figure out how Vermonters are going to equitably participate in this historic exogenous event in 2020 that frankly as Mr. Carpenter said as the payers they should be participating they're essentially giving back rather than just passing it on to the US Blue Cross said and I said earlier can really demonstrate nothing to show how savings are being generated thank you thank you Robert next I'm going to go back to Julie Wasserman who has her hand raised again thank you this is my last comment and it's in line with the last couple comments $23 million here's a lot of money and Eva will pay $15.4 million of that Medicare will pay $7.9 million actually it's $24 million because MVP is going to be paying $1 million so taxpayers might not like the idea with regard to Eva paying $15.4 million taxpayers might not like the idea of the state giving this large sum of money $15.4 million to a private entity and they might in fact instead prefer that these healthcare savings accrue to the state that's actually an option Eva on January 1st will become a state run Resparing Medicaid Managed Care Organization and under that scenario the savings would instead accrue to the state in the public's best interest so we're talking about a lot of money here and as former public comments made these are really the public's dollars and yet we're giving of it to a private entity and the state is not realizing the savings thank you thank you Julia we understand the point pretty clearly Robert Hoffman yeah I just want to also underscore if if folks think that the legislature isn't catching on to this they don't see the little trickery that's happening you folks are sorely mistaken there's a growing storm inside the legislature that's getting prepared to make big changes because this is not working and frankly there are going to be studies coming out in the near future there's enough data that's accrued at this point that's going to clearly link the all-payers capitation and global budgets and the lack of any demonstration of improvement projects to the limited access to care increased morbidity and increased mortality thank you thank you Robert is there other public comment is there other public comment if not I'd like to thank all our presenters this afternoon it was a great conversation especially to see MVP as part of this conversation today and with that I want to thank everyone especially Michelle and Sarah and is there any old business to come before the board at this time hearing none is there any new business to come before the board at this time hearing none is there a motion to adjourn so moved it's been moved it's been moved by Member Holmes and seconded by Member Pelham to adjourn all those in favor please signify by saying aye aye any opposed signify by saying aye thank you everyone rest of the day and as Susan said earlier we hope that everyone has a really great thanksgiving and gets to spend some time with family and friends thank you everyone thanks everybody