 Good afternoon and welcome everyone to the Green Mountain care board meeting. My name is Kevin Mullen chair of the board The first item on the agenda is the executive directors report Susan Barrett. Thank you, mr. Chair I don't have a Significant amount to report out only just to remind folks that they should just keep an eye on our Website and our Press release for upcoming meetings We have a couple of meetings next week and the week after that our TBD But we will certainly warn those Meetings if there anything if there's anything added to those agendas and will adjust the press release and I and I believe there Already was an addition this week. We added a primary care advisory group on Wednesday October 21st, so just keep an eye on that and that's all I have to report out Thank You Susan. The next item on the agenda are the minutes of September 29th and September 30th. Is there a motion? It's been moved It's been moved and seconded to approve the minutes of September 29th and September 30th without any additions deletions or corrections Is there any discussion? Hearing none all those in favor signify by saying aye Aye Those opposed signify by saying nay Thank you everyone So the first item on this afternoon's agenda will be a Discussion of the quality standards and for that I'm going to turn it over to Michelle degree to tee that up Michelle Thank You chair Mullen. So We are here today to discuss the final 2019 quality results For the one care payer specific contracts and so as GMCB staff I'll be wearing two hats today. I thought about actually like bringing hats, but I didn't So the first one will be as GMCB staff just overview of the program requirements And what we're looking at here today and the second sort of role that I'll play today is in reviewing the actual Medicare results for 2020 2019 not 2020 for 2019 So what I'm gonna do is Introduce everyone that I have with me here today. So from diva, I know that I have Pat Jones and Amy Coonrat on the line From Blue Cross Blue Shield. I have Andrew Garland and Tyler got here and joined from one care of Vermont So hello to everyone What I will do is share my screen and I will advance the slide throughout the presentation So once I'm done, I'll pass it over to Medicaid and just give me a signal and I'll I'll advance the slides for you so First things first just a quick agenda for today, but I just kind of went through but I'll be providing some background Just on the results that we're looking at here today Then we'll review each of the payer results. So we'll start with Medicare Then we'll go to Medicaid and commercial and then there's opportunity for the AC to provide comment This isn't the same format as we did this presentation last November Then we'll go to board questions in public comment Starting off with some background I Just want to kind of remind folks that today is about assessing performance on the ACO Quality measures that are set forth in the payer contracts between the ACO and the and the payers This is not an evaluation of the all-pair model quality performance as a reminder We measure all-pair model quality report performance annually It's very likely that those results will not be released until early 2021 For the 2019 year, we're just starting to get some of those data in obviously We have the payer specific data But in terms of the claims based measures that we need to evaluate we need a little more time for claims runout And for the 2019 year to be finalized So that said Again Just noting this is solely a reflection of the ACO's performance relative to payer contracts is not necessarily Reflect the ACO's contribution to the state's performance within the all-pair model agreement Though I will say we're currently exploring ways in which we can interpret these results in the context of APM performance And I'll talk a little bit more about our thoughts on that a little later in in the presentation So under the agreement just a reminder that the ACO is a legal organization of health care providers that agree to be accountable for the quality Cost and care of the beneficiaries assigned to it The ACO skills target qualifying programs must reasonably align in their design across payers, which includes ACO payer quality measures And so you'll recall that back in 2018 We did a significant amount of work With the HCA and one care around designing the Medicare measures and starting in the 2019 year So we'll see those results Here in a moment My famous crosswalk that I get to update every year So this year we're actually looking at the full suite of all-pair model measures here in the first column And you can really see that We're starting to see some pretty great deal of alignment across payer programs So you have the 2019 Medicaid next-generation program in the second column The third column is the 2019 Medicare initiative and the fourth column is that Blue Cross Blue Shield next-generation program I do want to point out a couple of quick notes here For example the initiation and engagement measure Blue Cross does treat those as a composite The all-pair model the Medicare initiative and Medicaid next-gen do treat those as separate measures And so anywhere that you see sort of that locked cell is just to indicate that the payer in that case That's those as a composite measure Another note here just before we get to into the weeds Caps measures. It is the consumer assessment of healthcare providers and systems. Those are the patient experience surveys And each program has some type of caps survey and that they Distribute but they're not necessarily all the same and so a couple of quick examples The all-pair model includes the cap survey Composite of timely care appointments and information for ACO attributed Medicare beneficiaries only But the Vermont Medicaid next-generation program Includes multiple caps patient-centered medical home composites you have The Medicare initiative using multiple ACO caps composites for attributed Medicare beneficiaries and similarly with Blue Cross They include care coordination composites and tobacco cessation questions from the caps patient-centered medical home group and just to consolidate this List a little bit. It was easier to make those sort of one lump But each payer and goes into detail about the caps specific measures within their programs So with that just moving forward While working towards pair lineman is a primary objective not all pair programs are equivalent in terms of quality requirements Again, you'll recall in 2018. We went through that work group to develop and propose the measure set in the Medicare initiative From 2019 to 2022 and so similarities across the programs are much more noticeable in the 2019 program here than they were in 2018 and differences that remain are primarily due to types of covered lives or aligned beneficiaries And and make quite good sense. So for example, there's a lot of a couple of adolescent measures for Blue Cross and Medicaid Populations but not necessarily for Medicare and that just makes sense based on their covered population So I know there's going to be a lot of Questions about what can we say year over year in terms of Advancements or changes in quality and so while we do now have two points in time Comparability is still a challenge for us and I apologize if you can hear my dogs So performance year one 2018 and performance year two 2019 data have been finalized We're working with our analytics team as well as some of our outside experts to dig into changes in quality associated with shifting populations and other factors And so just to sort of highlight that I wanted to show A quick snippet, you know, we've we've now produced two scale reports also And so this is just showing really that population shift so the increase in the Medicare and Medicaid populations and that Small decrease in the commercial program from 2018 to 2019 To just show how that shifting population has the potential to impact our results and our quality measures And again, that's something that we're looking into and how we can address to start to look at this more longitudinally Okay, switching my hat Medicare results for 2019 Uh, so in 2019 similar to 2018, there were four domains for Medicare We have patient and caregiver experience, which is worth 20 points I just want to note here. That's half of the total points and they're all based on those CAP survey questions. So that's patient experience Accounting for half of the total points available There's a care coordination and patient safety aspect Two measures there. There's a preventive health Section those there are four measures there A couple of notes on these so for preventive health in the at-risk population There were measures that were initially slated to be paid for Performance and they reverted to pay for reporting Um as all activities related to the quality measure validation audit for 2019 year were canceled And that's due to the public health emergency So that was a choice by cms to revert those measures to pay for reporting since they could not Perform the audits necessary to give a total performance for So here's the 2019 results I know this is kind of small, but I can leave it up on the screen for a bit while we start to talk through it I did want to note so I tried really hard to come up with a creative way to show 2018 compared to 2019 and this would be easier So every measure that has a star next to it was also reported in 2018 And so those will be part of the measures that we look into or that we work with one care on Thinking about how we start to look at these in a longitudinal manner How do we think about the population system of these and how do we You know start to to think about how to really trend this data Um, we don't want to make assumptions based on this because we know there was a pretty significant growth and that just that you know The overall denominator would have a pretty significant growth um So a couple of notes here for the for the medicare results specifically Caps measures combine responses to several questions and as such performance on caps don't represent an actual percentage But rather the acos mean or average Um, I can't say whether or not that's consistent across pairs I would imagine because they're all sort of on different planning scales But I just wanted to point that out. So in most cases, this is a percent score In the case of caps. It's actually just the average score The risk standardized and the all condition readmission measures So those both of those care coordination and patient safety measures are actually inverted So a lower score is going to be better there Um, and you'll see in a future slide. I made a mistake. So Abigail I will have to update our Our slides, but I will I promise I'll do that um and For this at risk population section down below here This is where you start to see the inclusion of those Those measures that are also part of our all pair models that that were not uh Asked of the aco in prior years. So that's where we look at follow-up after discharge form from the ed for mental health alcohol or other drug dependence um And then mental illness and then the initiation and engagement measure looking at that for the medicare population as well Okay So for 2019 quality results There were 20 measures total. So again two point maximum allows 40 possible points The aco's earned score was 36.75 which results in about a 92 percent quality score for 2019 and again just to note that those Related those that required a qmv audit were canceled And so there were five measures that the aco did receive full points just for reporting on Um, and again when these results when the all pair model quality results are final We'll work to figure out how these pair specific measure results impact the state's performance And we'll have more insight as to how to look at these longitudinally That's something that myself and the a team are really Interested in exploring and and trying to make sure that we can provide an accurate snapshot of performance year over year for the model I did want to give you a quick reminder of 2018. So jumping back a year We went from 29 measures to 20 in the 2019 year. So last year there were 58 points available and the aco earned a score of 82.4 percent And so here's where I made a mistake So of the 16 measures that were carried into the 2019 program improvement was noted in 14 of those measures not 12 so there were Three measures where a decline was noticed and it was very minimal Those were in the timely care appointments and information caps composite The um caps stewardship of patient resources And risk standardized all condition Re-admission and I just really want to stress how minimal the declines for um, and I I'm working with the MMI to see if They did any statistical significance testing on those results to see if there really is truly a statistical difference in those scores Something to just quickly talk about in terms of medicare Most notably kind of the exogenous specter here of COVID-19 and the public health emergency Really impacting some of the ability to score Appropriately for the 2019 year In addition we talked about this but the growing provider network and payer churn And then for for medicare specifically the Vermont population demographics. We know that we have An aging population and that Acuity and disease burden within that aging population is higher And these are just sort of caveats that we're looking to see if how we're Looking into more detail to see how these might contribute to our overall results And last but not least Back into my gmcb hat um I really discussed some of this ad nauseam already, but gmcb staff In the near term are going to dig into the impact of acl payer quality outcomes on our states 2019 quality performance under the model And we'll certainly be bringing those insights before the board again likely early in 2021 Uh, we'll be working to untangle year over year quality performance from changes in metrics due to increased scale or changes in the population um, and per the 2020 budget order the acl and the gmcb staff are working to develop a dashboard that include acl and hsa level quality results over time and for The gmcb staff are creating and publishing data visualization of cumulative apm quality results And this adds to our existing available resources On our tableau site for things like total cost of care and scale participation Looking forward to 2020 just a couple of things that I want to note that we've heard from medicare already Medicare at this point is slated to be paid for performance or for monitoring purposes only this is subject to change And then currently the cms proposed rule Suggest the removal of the caps requirement for all acos in 2020 So full credit would be awarded, but the survey itself would not be administered So again, this is in the proposed rule the cms rules don't become final until usually about mid november So we've got at least another month until we know about that um And Another note is just that utilization for 2020. We already know is pretty significantly down So we're going to have a pretty small n here to work with and so just thinking about What 2020 looks like in the grand scheme of you know, the agreement and the five-year term um, and then just another note that the federal evaluation of the all-paramodal agreement includes an analysis You know and quality outcomes across per month As well as at the aco level over the life of the agreement, but these results won't be available until at least 2023 So we've got some time before we would we would see those and our hope as stuff is to make sure that we can start to incorporate um Some of these analyses a little a little earlier down the line So with that, I'm going to turn it over to Medicaid Amy and pat if you just want to let me know when you'd like me to advance your slide Hi, thanks michelle. Can you hear me? Yeah, great. Okay. Hi. Um, so this is Amy kuhnrod, and I'm the director of operations for aco programs over at diva and I am here with pat jones to give a brief overview of The vermont medicaid next generation aco programs quality performance for the 2019 performance year If you'd like to advance the slide, that'd be great. Great. Thank you um So 2019 represented the third year of the vm ng aco program between diva and one care Which as michelle mentioned earlier involved 13 communities and an attributed population of around 79,000 medicaid members, which was a pretty significant increase in the attributed population from 2018, which was around 42,000 um As folks know as a value-based payment model the vm ng program campaigns of quality measures that and an associated value-based incentive fund part of the aco's fixed perspective payment is set aside every month into that fund and After the performance year that part of money is distributed to the network Based on the aco's performance on the quality measures that you see up here on the screen For the 2019 performance year the equivalent of two percent of the total fixed perspective payment for the aco from diva Was set aside into this value-based incentive fund That percentage has increased Every year since the program's inception I'll just give folks a refresh that in 2017 the value-based incentive fund Was 0.5 of the fixed perspective payment and in 2018 it was 1.5 of that payment that was set aside into this fund After the performance year the quality performance is calculated at the aco level And then a proportion of the incentive fund is distributed to one care's provider network based on its performance Half of those undistributed funds that are left over are reinvested by one care in quality improvement initiatives at the aco level And the other half is returned to diva during the financial reconciliation On this slide specifically as a reminder This table contains the aco's quality measure set for the 2019 performance year of the vmng program The set contains 10 payment measures and three reporting measures one of which is that caps patient experience survey These measures were selected to align as closely as possible with the quality measures for the aco's other payer programs As well as the overarching all-payer model quality measure set But there are differences as michelle's beautiful crosswalk chose To ensure that the measures are appropriate in the vmng program for the medicaid population Next slide please great So in terms of scoring there are a total of 20 points available for the 2019 performance year And each of the payment measures was weighted equally within the set and was scored individually Where possible One cares measure results were compared to national medicaid benchmarks, which were available for Eight of the 10 payment measures in the set If medicaid benchmarks weren't available at the national level or multi-state level The 2019 results were compared to one cares performance on those measures for the 2018 program year Which was the case for two of those 10 payment measures Beginning with the 2018 performance year as well and continuing into 2019 One care was also able to start earning bonus points for each measure That had available benchmarks or demonstrating statistically significant improvement over their prior year's performance Um, I went through that really quickly, but I would like to now Turn it over to my colleague pat jones Who will more specifically to one cares actual 2019 quality performance? Great. Thank you. Amy and good afternoon to everybody So i'm going to give a high level summary of the aco's performance in 2019 and then in our last slide I'll really dig into detail on how they performed on each of the measures So for 2019 the aco's overall quality score was 95 percent For the 10 payment measures and that compares to a score of 85 percent in in 2018 As amy mentioned there are eight measures for which we had national benchmarks and for three of those measures One cares performance succeeded the national 90th percentile and we tend to think of 90th percentile is The highest achievable benchmark. I mean that that that's a very high level of performance So that was the case for three of the measures There was one measure and that's the developmental screening and the first three years of life measure Where there is no 90th national percentile The measure comes out of or again It's used widely by cms and by many states But the highest published benchmark we have for that is the 75th percentile and in the case of that measure One cares performance succeeded that national 75th percentile For another measure One cares performance was between the national 75th and 90th percentile For two measures their performance was between the national 50th And 75th percentile And then for one measure it was between the national 25th and 50th percentile And I'll get into detail on which measures fell into which category As Amy mentioned national benchmarks were not available for the remaining two payment measures So in lieu of of that one cares 2019 performance Was compared to their 2018 performance and for both of those measures performance improved in 2019 For five measures In this set there was statistically significant improvement from 2018 to 2019 And that includes one of the measures one of the two measures for which there was not a national benchmark So michelle if you could advance Great. Thank you So I want to start with the key Because this describes How points are assigned for performance for each of the measures So for measures where performance is equal to or below the 25th percentile No points would be awarded For measures between the 25th and 50th percentile a half a point Would be awarded above the 50th percentile one point Above the 75th percentile one and a half points with one exception Which is that measure the developmental screening measure where there is no 90th percentile In that case, um, they were awarded two points for performance above the 75th percentile And then above the 90th percentile also two points We don't um, we don't Put our measures into domains the way that medicare does but I do want to note that The measures Broadly follow some of the areas the high level goals in the all payer model So we have um mental health measures We have two of those out of the 10 measures We have three measures that speak to treatment for substance use disorder We have three measures that speak to Treatment or really in the case of these measures It's heading into the territory of outcome measures For chronic conditions And then we have um a couple of more preventive care type measures as well So if you look at the um at the table What we've shown is a brief description of the measure The numerator and denominator We show the 2019 rate and that's where the key comes into play. That's where we show You know this the scoring The 2018 rate is provided for reference When we have national benchmarks, we provide those at the 25th 50th 75th and 90th percentile We then show the points that are awarded for performance And then bonus points awarded if there is statistically significant improvement So the first measure is 30 day follow-up after discharge From the emergency department for alcohol and other drug abuse or dependence For that measure, um the aco was in fact Above the 90th percentile benchmark It was an improvement over the 2018 rate And in fact, it was a statistically significant improvement so that um resulted in one bonus point A companion measure to that is the 30 day follow-up after discharge from the ed for mental health And again, in this case, the aco performed in excess of the 90th percentile It was an improvement over 2018, but it was not a statistically significant improvement And so there were no bonus points for that measure The third measure is adolescent well care visits This is our measure with the largest denominator by far In this case, the aco's performance was between the 50th and 75th percentile And so they were awarded one point for that performance It was a slight increase over 2018 But not enough to achieve statistically significant improvement The fourth measure all cause Planned admissions for patients with multiple chronic conditions There are nine chronic conditions outlined in this measure So people with two or more of those chronic conditions are considered as eligible And it's a risk adjusted measure that looks at whether there are planned admissions This is a measure where a lower rate is better And so in this case, the aco did see improvement The rate went down from 2018 to 2019 This is also a measure where we have no national benchmarks And so in this case, even though the aco improved It was not a statistically significant improvement And so they were awarded one point instead of two points for their performance on this measure The next measure I've already talked about This is a developmental screening in the first three years of life This is a measure that does not have the 90th percentile benchmark The aco's performance is quite a bit above the 75th percentile It also represents a statistically significant improvement from 18 to 19 So they attain the two points for performance and the additional bonus point Diabetes, hemoglobin A1C, poor control This is one of our chronic illness measures It is considered an outcome type measure This is a measure where also a lower number is better on this measure And so once again, the aco improved from 2018 to 2019 The rate was better than the 90th percentile And the change was statistically significant So in this case again, two points for performance and the additional bonus point Hypertension, another chronic illness measure, controlling high blood pressure This measure, the aco performed between the 50th and 75th percentile This is a measure where there was a slight decline in performance from 2018 to 2019 Not statistically significant, so they did not lose points for this As a result of their performance, they achieved one point Initiation of alcohol and other drug abuse or dependence treatment This is a measure where the aco performed between the 25th and 50th percentile This is a measure that we've been working on intensely in Vermont It's a challenging one Because of the aco's performance on this measure, they received only a half a point And the companion measure to that, Michelle mentioned this in her comments But some payers look at this as a composite In our case, we look at this as two separate measures And it looks at after sort of the initiation visit That's the person receive at least two more visits in the next 34 days After a new diagnosis of substance use disorder And so in this case, the aco's performance improved from 18 to 19 And it was a statistically significant improvement So they got the bonus point Their performance was between the 75th and 90th percentile And so they got one and a half points for this And then screening for clinical depression and follow-up plan This is a measure where, again, the aco improved from 18 to 19 It's also a measure where we don't have the national benchmark So we looked at change in performance over time This was a statistically significant improvement And so they received two points So the total points with the performance points And then the statistically significant improvement Resulted in 19 points out of 20 potential points So that was, again, an overall performance of 95 percent I just want to say, you know, from our perspective This is strong and very encouraging performance To have this many measures above the 90th percentile Above the 75th percentile Seeing this level of improvement from year to year These are really encouraging results And I think reflective of the really hard work And good work that providers in Vermont Are doing on behalf of Medicaid beneficiaries So that does it for our presentation And thank you very much for your time and interest Thanks, Michelle, can you hear me okay? Yes Great, okay My screen is not synced up with my audio here But I think it's working all right So hi everybody, I'm Andrew Garland I'm the Vice President of Client Relations and External Affairs From Blue Cross to Shield of Vermont I have to admit I'm somewhat pinch hitting today This isn't my area of expertise But the person who would normally give this presentation Is unavailable today Joining me is Micah Devers One of my colleagues He's in our quality improvement area He's really an expert in these measures And Micah agreed to join today In case you have a detailed question So I'll take us through the high level And then we'll see where your questions go So with that, Michelle I think you can just turn us to the next slide And I'll start just by saying That this is really important to us And I'm thankful to the Green Mountain Care Board And to Medicare and Medicaid And all of the folks on the line today For the dialogue The all-payer model And the work that the ACO is doing Is directly aligned with our mission And our vision for a healthier Vermont And a healthier healthcare system for Vermont So thanks everybody for this dialogue I'm excited to be talking with you today So I thought as a next step On the next slide, Michelle We can talk a little bit About what our program looks like in 2019 These are just some of the high levels And I'll slow down on the quality Aspects of the program So this is a qualified health plan program In 2019 You probably know we had a pretty dramatic expansion In 2020 bringing a number of large clients Into the program But this analysis of course predates that The basic financial arrangement in 2020 Was shared savings As Michelle showed in her great slide Our metrics are a subset of the larger set And we selected metrics that really resonate For a commercial population As others have noted That the needs and challenges Of our population are a little bit different Than those that Medicare And Medicare are facing Medicare and Medicaid are facing Our program works in a slightly different way We ask one care of Vermont To set aside every year Dollars that equate to about 1.5% Of the total cost of care And then they either distribute those dollars Out to the providers in their network Or they retain the dollars To reinvest in quality program Depending on their achievement On the scorecard each year So for points they achieve That frees up dollars to Distribute out to the network And for points that are missed Those, that share of the dollars Or the dollars that correspond to those points Stay with one care To be reinvested in next year's quality program So the idea is Whether we're hitting the measures Or missing them Or not hitting them as hard as we want Either way we're reinvesting In the network's ability To deliver quality improvement to our members We do have in our contract Some collaboration requirements So we really try to stay close To one care as they're doing this work We recognize that Blue Cross with Sheila Vermont Is a very important supporter So we pay close attention to what's going on And we ask it every step What can we do to help And then I'll just note that There was a pilot program going on in 2019 Actually continues to this day With the University of Vermont Medical Center As our first ASO client To be participating in the all fair model With a relationship with one care Vermont I won't be reporting on those results today That's a very, very small pool And I don't think we would want to equate their results With the QHP and reporting on them independently I think it's not going to tell us much Just because the number of members is so small And then on the next slide Before we dive into the details I thought it was just worth reflecting a little bit As Kelly did when she made this update last year On what some of the bright spots and challenges are That we face When we look back at the 2019 Arrangement with one Karen Some going forward You'll see I snuck a 2020 on there at the end of the challenges Because I have the life space to do so Maybe most important on this slide Are those first two bullets under bright spots And really taken together To me they say that the Blue Cross team And the one care team Have a great collaborative approach to doing this work You know, if I look back at this arrangement And I've been working on payment reform in Vermont Since I started on payer-related work Or provider-related work back in the mid-2000s I would say that up until two or three years ago Most of our work in this space Could still be characterized by the word negotiation When we worked with the ACO Or other provider organizations before this The tone of the conversations in both directions Was really dictated from a contracting point of view Always negotiating on behalf of our organizations But I feel like in the last year or two with one care We have really moved past that dynamic And fostered a new dynamic that would be better Characterized by the word collaboration And as we've encountered a number of challenges Sort of external to the program But the challenges that nonetheless have impacted The program the most obvious being the pandemic We've been able to respond together quickly And in virtual lockstep in a way that I just think We wouldn't have been able to do for five years ago So that's really remarkable It's an extremely strong base to build from Another really great accomplishment for us in 2019 Though it didn't technically go live until April of 2020 Was the work we did together to build the first commercial Prospective payment system Sorry about that title Prospective payment system And one of the first that we know of Of its kind in the nation And that was a really challenging undertaking Particularly on the psychology side And we're really thrilled with what we accomplished together On the challenges side Again, I would take those two bullets The first two bullets together I think they're largely saying something very similar Which is it's still difficult for us to look at All the data that we have on our members And clearly distinguish the line between those that are in The one care model and those that are not So one of the challenges of using this Type of quality scorecard program Is that it's not as directly tied To the work that the providers and the folks at one care Are doing every day as we would like And these are pretty bottom line measures And there's an awful lot of things that can affect them Between the work that the providers are doing And the time that we actually get around to measure this But you'll see it's not got a bright point in there Under that first challenge We've already worked with one care To come up with a new approach To our scorecard program for 2020 So that we're not relying so heavily on Measures which are so far downstream But will have more built into the program That really allow us to see One care's work plan And you know look more closely at the results That are coming directly out of their actions So that's pretty exciting stuff And then a final point You know I heard the host Sarah Michelle makes this point Which is talking about the Medicare program COVID-19 a major disruptor Both on our ability to measure quality results But of course as we move through 2020 and into 2021 A major disruptor to providers And their ability to engage with us On any new quality improvement initiatives Whether they're through the all-payer model Or things that Blue Cross and Shield of Vermont Would be working directly on So I think we'll obviously have a very different discussion When we're together next year To look at the results of 2020 Okay so let's Oh right a few other things I wanted to point out There were some really exciting Collaborative initiatives that we worked on together In 2019 and some more that we have underway in 2020 I mean the two most exciting for 2019 here on this page One was us really working differently with one care To try to provide to them actionable practice level data And rather than relying only on high level data extracts Our quality team packaged some information To make it easier for them to serve out Things that could be given directly To the provider population To help move the needle both on the mental health Substance use disorder side And then also as you'll see And data related to some of the quality metrics On the scorecard And then we also started working with them in 2019 On a really exciting program That's a little bit aside from the quality scorecard Or much higher up to get more folks into primary care One of the things that our quality team That our nurses work on all the time Are interventions designed to find those members On our books who are not accessing their Their primary care position services regularly Trying to make contact with them And encourage them to go in and use Those preventive benefits that are available to them So in this initiative we've worked with one care To try to move some of that communication And encouragement from Blue Cross Blue Shield Of Vermont directly to the primary care position office With the idea that people are more likely To pay attention or respond If they're getting that encouragement directly from their position So that's pretty exciting work And then on the next slide I just listed out some other chronic condition Some other chronic condition management initiatives That we had conceived and begun talking to One care about even before the pandemic And you'll see that they all involve Some form of telemedicine or telemonitoring So we're encouraged that These are initiatives that we'll be able to continue to pursue Through 2020 and 2021 Even in the face of this very different pattern Of utilization that we're seeing across Vermont Because these still involve Our telemedicine or telemonitoring So they're things that can go on even in the absence Of the same kind of in-person care That we are used to seeing before the pandemic So I've deferred a big finish here A lot of suspense to the actual scorecard So our scorecard has just nine measures on it That are considered for payment So these are the nine measures That affect that half a percent That one care sets apart As Michelle indicated at the beginning Of the presentation We also look at a number of other measures Caps measures primarily Those are reporting only measures You can see here that Where we've indicated a check mark One care achieved full quality measures On a particular measure And they did that by exceeding That national 90th percentile that Pat mentioned And we did make a change to our program In 2019, I believe So that in order to achieve full points On a measure Even if it's a measure that's as tough as say That initiation engagement of alcohol And other drug dependence treatment Where our starting point is way down Below the 25th percentile Or around the 25th percentile In order to achieve full points They have to get to the national 90th So in one care was willing to take on that challenge Really to recognize that we shouldn't be satisfied And say that we've fully accomplished What we needed to accomplish on any particular measure Until we're the best in the nation Our program also allows them to earn some bonus points For having statistically significant improvement In at least two measures In any particular measure And they did that on two measures last year So I didn't indicate this on the slide I'm not sure why I apologize They earned 14.5 points out of a potential 18 Because of those bonus points Which I think equates to about 81 percent Of potential points And you can see measures like that Initiation engagement of alcohol And other drug dependence treatment It's a long haul for us to get that up To the national 90th So we would not have expected them to get to 100 percent That's a really, really high bar to accomplish But still the way we've structured the program The dollars that don't flow back To the provider network again Remain with one care To reinvest in work on those measures That aren't at the national 90th this year Another thing you've probably noticed on this slide It's kind of jumped out There's the ups and downs I think it's important to keep in mind That even though this is a fairly large pool It's still a fairly small pool So the denominators on some of these measures Are relatively smaller I think are going to be significantly smaller Than what we would see either in the Medicare pool Or the Medicaid pool So we would expect some more ups and downs And then I did take a few minutes and look back at the I looked back at the 2018 scorecard Just to remind myself And though the point system was a little bit different The overall accomplishment is pretty significant We had three measures in 2018 That were at the national 90th Statistically significant improvements In a couple of measures And then a couple that swung in a different direction So you know consistently good work here And we're really optimistic about House government operations committee We are gathering here this morning To and beyond as we move into this new approach That takes more of a work plan approach And the scorecard is de-emphasized a little bit We'll still of course measure all of this stuff You know that's extremely important But moving the payment The payment part of the program To be more directly tied to the transformative work Will be a really interesting experiment And we're thrilled that one care was willing to go there That's all I had I'm not unlike Pat I can't take you through these measures one at a time But I think she covered all of them in her slides So thank you Thank you Andrew So with that we'll turn it over to board questions And you've got the full panel here Including Tyler from One Care To jump in and answer any questions That you might have for them as well Or any questions that us payers can't answer So I'll start off Pat as really the mother of the quality Measures in the state of Vermont Is there anything that jumps out at you that is alarming you? No, I don't think so I do think that you're seeing where some of the challenges are Initiating in particular And even engaging people in substance use disorder treatment Is a real challenge And I'm sure there are multifaceted reasons for that That have everything to do with capacity, geography But those are even the engagement measure Where we tend to do well If you look at the absolute rates Both for Vermont and nationally They're very low And so just continuing to work in those areas Where we know that treatment helps And we've done a lot in this state In terms of access to treatment And types of treatment But that continues to be a concern On the plus side Seeing some of the improvements And some of the outcome measures Like the diabetes for control measure And just seeing the across-the-board improvement And the rather high level of improvement Anything above 75th percentile is strong performance And so it's really again I just want to say it's a reflection Certainly of the work that people have done together The ACO payers, aligning measures But also the providers really doing the hard work Of quality improvement That to me is very encouraging So I saw much more to be encouraged about Than to be alarmed about Any questions for board members? I had one question for Pat as well When you look at the quality measures Where we were saying the achievement Was I think 19 out of 20 But when I look at it I'm looking at it, it was like 15 out of 20 And then there were four bonus points So how do we look at that? Because wouldn't that really be There were 24 possible points? There's more than that But they achieved some bonus points So there was 15 out of 20 And then they got four of the bonus points So even if I said it was 15 out of 24 I just want to make sure we're reflecting The right percentage of how we're doing And obviously we're making improvements In a lot of places But I just wanted your reaction to that Right, in keeping the idea of the bonus point Was to allow them to earn more We did not change the denominator So if you look strictly at performance It was 15 points for performance I will note that if they had statistically Significantly decline They could have lost some of those bonus points as well But there's no question that was an opportunity To for them to increase the score I, you know, I was I think we were pleased And surprised at the level to which Those improvements were statistically significant Because that's a, you know, reasonably high bar Yeah, I'm not trying to penalize I'm just trying to look at it Yeah You know, from different ways of the math So thank you Yeah So I'm just kind of looking at slide 14 You don't have to go there But it's the verbiage was that of the 16 measures carried into 2019 Improvement improvement was noted in 13 measures And I'm just wondering what does improvement mean Because when we get down into Medicaid And I have a question there But in Medicaid they're talking about statistical Significant differences And in Medicare its improvement was noted And so I assume that's on that 90, you know Percent on that percentile And was there a spread that was Assumed that if the measure increased by a certain number in the spread It would be considered an improvement Yeah, so for Medicare We do not yet have the statistically significant analysis done From our federal partners And so that's something I'm waiting on So like I said in those measures where we did not see an improvement We saw a decline in the score It's so minimal in so many cases that we're I'm not sure if it's statistically significant or not And the same goes for the noted improvements There are some where I could make an educated guess And say that I think that they would have statistically significantly improved Just based on that sort of gap But without that analysis I'm not comfortable in answering that on their behalf Once we do have that analysis I'll be sure to pass it along to the board And we can certainly do an update to this presentation Unless one care happened to have that And I do not But I do think if you just compare the two And see sort of that prior year performance rate And then against the 2019 performance rate But again trying to keep in mind That something that we're working through is taking into consideration Those massive changes in the scale population And changes in the denominator overall And sort of what impact that has on performance Okay and then so looking then at Medicaid And it's a you know five measures There was statistically significant improvement And there was the point of the bonus point approach But what can you talk a little bit more about What statistically significant means in that context I mean what is the hypothesis that X caused Y And so there is a spread in the numbers But is it just the fact that it's associated with the ACO Or my phone's ringing in the back I'm sorry I don't know if you can hear it But so I just if you could have a few more sentences about I mean you know how can we be assured That the statistically significance is aligned With these measures in the ACO program Yeah thank you Tom I you know I think all we can say When you're looking at statistically significant improvement Is all you can say is you know the measure improved And probably at a level that was not due to chance You know what the factors were in that improvement Whether we're reaching a level of alignment of measures And a critical mass of attributed folks That you know that that provider that allows providers to really focus on this I don't know that we can say that But you know to have year over year improvement That is statistically significant Seems like we're really going in the good direction I mean most of our measures improved We saw improvement But half of those payment measures saw improvement As statistically significant level You know I think as Michelle said There's a lot of digging into as to the why And how best to capture this but Directionally things look good at this point Yeah I would agree that I mean the flow is in the right direction And we have two or three more years at least within the all pair model to kind of Continue to track this and learn more and and have more data I just I just you know because of some of the controversy around the ACO Aligning and linking these quality improvements and this positive flow To the ACO I think is an important Consideration as opposed to saying some of the Medicaid numbers are better Because over in the education department You know for kids on Medicaid they improve nutrition You know and it's kind of like you know in a different arena So you know it's obviously the directions In you know in a positive way and that's a good thing The final my final thing is For Blue Cross Blue Shield now that Blue Cross Blue Shield is Engaging with the ACO I I wonder if And I could be totally off base on this but but to me the benchmark plan for the QHP population Hasn't been kind of reconsidered since its inception which I think is in like 2012 or 2013 was The basis for that plan and and one of the areas for example that we see here is diabetes And one of the areas you know in the benchmark plan is diabetes But there's no organized program in the benchmark plan to avoid the diabetes There's no organized pre-diabetic program and I'm just wondering if Blue Cross Blue Shield might kind of urge the ACO and other partners and participants to revisit that benchmark plan In order to make sure it's as aligned as possible With the goals of of the quality goals that we're talking about here I you know I do understand that some who were there when the benchmark plan was first crafted that It was kind of a food fight with everybody trying to get their you know their their Service Engaged but you know, I think you know folks can say there's a limit here We're just looking at prevention now in terms of the restructuring of this benchmark plan And move forward in that regard Yeah, thanks. We we have introduced some optional plans that are really focused on some of the issues that you That you described Tom, but I I'm sure the folks on on our team who are working every day to to Design benefits would would be thrilled to sit down, you know with other stakeholders and look again At the benchmark designs and ask, you know, you know now that we know what we know Where the network is able to engage? How can we do this? How can we do this better or differently? To make it easier for members to make those connections and that that's a The question that's on our minds all the time in fact, I have a task force working on this This question of why why why are people not taking advantage of zero cost share services? Which we know they need and and we tell them they need and they acknowledge and still say well We're not going to go because we're worried about cost So I think those are really important issues and and I will absolutely pass that engagement along Thank you other questions from the board Hi, this is robin. Um, I had a follow-up question for andrew related to The work plan approach. I was interested in hearing a little bit more granularity about how you're thinking of approaching that and um Just maybe giving a couple of examples about how you would use that for the quality measurement Yeah, well, I will admit that we are still working on the specific So if I don't offer them, it's not that I'm being evasive, but the the idea is that instead of saying You know, let's let's move the money around based on the results for adolescent well care visits We want to move that question upstream a little bit or downstream I guess depending on your perspective and we start by asking the aco Okay, well, what are the plans for 2020 for 2021 to move the needle on adolescent well care visits? Let's show us that work plan and let us Let us sit down together and agree on a point structure that is tied to some of those activities That you specifically hope to to put in place and let's find some measurable Between the work and the very very sort of downstream quality measure To see if we can get a better sense of how the action Is is turning into results because to tom's really good question and pat's great answer It's hard to tell. I mean this says as everybody knows there are so many dynamics at play in this healthcare system And you know when you push on something Whether or not the thing that's you know 15 dominoes down the down the line actually falls Can be really hard to know, you know, did it fall because of that push or did something else come in and and influence it So so that's the change we're trying to affect there. I think we'll have a better sense Over the next couple of months what that's going to look like specifically But we were we were really thrilled that the DACO was open to making that kind of change Yeah, it sounds like an interesting approach because I I do think one of the challenges as we've talked about is And that's pat alluded to when referencing scale is that the quality measurement results here at the individual provider level And so there could be a lot of different things going on in an individual provider's office that may affect those So that's interesting Um, I guess the other question that I had that I just wanted to ask The diva team and the blue cross team is Based on the quality measurement in In 2019 Where are the areas that you think it's most fruitful to focus on moving forward in the quality arena Given all the dynamics around The different areas I'm just curious if in your opinion on that I'll start with that. This is pat I you know, I think I alluded to it earlier, but I think continued work In the substance use disorder treatment arena Is is going to be really important you know and and partly because it It it rolls up into The tragedy of deaths from drug overdose and other morbidities From substance use disorder. So, um, you know given and it's a challenge. It's an all hands on deck Approach it's not that we can expect the providers to do this alone It's not that we Can expect the state to do it alone the payers to do it alone This is a multi-year All hands on deck effort And it's one of the really unique elements of our approach to quality, which is that, you know, we're looking at Areas that are You know, it's hard to to Improve in silos They involve public health efforts as well as clinical interventions and having capacity for treatment and Giving people the support they need to get treatment. But to me again when I