 Good morning. This is a joint meeting of the Senate Health and Welfare and House Health Care Committee. And we're going to be listing this morning a testimony from the Accountable Care Organization for the State One Care. So before we begin, we're going to go around this table and have everyone introduce themselves for folks. And then after that, we'll have a quick introduction to the meeting and then introduce our guests. So I am Senator Ginny Lyons. I chair the Senate Health and Welfare Committee. I am Bill Liburd, chair of the House Health Care Committee. So why don't we start over right here? So I'm Senator Brian Smith. I'm a member of the House Health Care Committee. I'm Peter Rita from Brake Tree, and I'm part of the Health Care Committee. I'm Marie Cordes, Lincoln, Bristol, Monk, and Starksboro House Health Care. I'm Ori Houghton, and I'm the extension of the House Health Care Committee. I'm Dan Duhue, Northfield, in Berlin. I'm Rich Westman. I'm the senator for the oil. I'm Davine, I'm a senator from Chittany County. I'm Dick McCormick. I represent the Windsor County District. I'm Lizzie Rogers, representative from Waterloo. Terrific. Thank you all for being here. This morning, we have a terrific opportunity to hear from OneCare, and then we'll continue, testimony tomorrow. So we get some of the picture today, and I know that we'll be hearing about the budget and financial issues. So that will be today, and then tomorrow we'll hear more about the quality metrics and measurements for determining quality improvement and other areas. Just contextually, I think we have been some significant concerns about OneCare, some of which have been slightly negative. Our goal is to listen to information to gather as much as we can, and then to make any decisions that need to be made without prejudice. And that is the job of the legislature, and we'll continue to do that. For some of us, OneCare is critically important for ensuring the stability and longevity of our community hospitals, as well as having those hospitals link some of the acute care, link with our community services. So as we go through this, and today and tomorrow, we'll ensure ourselves that we're listening for those important attributes. We know that OneCare is part of the whole system. We know that I see folks from the hospitals, the Green Bank Care Board, the administration, DEVA, our community, DAs and SSAs, and they're all so critically important for patient care in this state. So that's all I want to say, and I'll turn it over to Representative Woodford. Thank you. I simply say that I think we both or each of our committees has spent some time trying to understand the context in which OneCare has come into being in terms of the all-payer model and the health reform efforts through the all-payer model agreement. I think there's been a great deal of confusion at times, partly because of the language that we've used, that all-payer model and the Accountable Care Organization is an important part of payment reform, but it's not the financing reform that has been confused by the language of single payer and then moving to an all-payer model for payment reform, and I think it's been important for us to all understand that we've had many initiatives over the past number of years on Vermont Rapid Health Care. This is a payment reform initiative and not a financing reform initiative. Also, to say that a few years ago we put into place regulatory oversight through the Green Mountain Care Board of Accountable Care Organizations that had not been in place previously, and I think part of what our job is at this point as well to hear and evaluate whether there's further changes that need to be made in terms of regulation as we move forward. This is, as I've said to our community, this is not the, we're going to hear from one care today and tomorrow. We decided to do it jointly rather than, so we all have heard the same information, but this is not the only testimony that either of our communities will be taking. We'll be hearing from other witnesses as well. We want to give one care the opportunity to put their information before both of our communities today. So, welcome. So we have two members of the one care leadership and we will ask you to introduce yourselves for the record and then offer your testimony. I know that you have handouts for the committee. It's also on our web pages with the House and the Senate so accessible information. I think we're going to try to balance presentation and questions. We have, I'm sure there are questions along the way, but we're going to be meeting again tomorrow. So some questions, if it's a question that could be held till tomorrow, that might be helpful to get the presentation in front of us today. Let's try to think in terms of that, but we don't want to preclude the possibility of clarifying any other questions. Okay, so for the record, my name is Vicky Loner. I'm the CEO of one care. I think I've been well-known to many of you on the committee I've had a sheet of testimonies in the last few years. So I'd like to use a little bit of time to let my colleague, Tom Boris, who is the senior director of finance, tell you a little bit about himself and his background before I come back into my portion of the discussion. Thanks very much. Very happy to be here. Thank you for the opportunity. So my name is Tom Boris, senior director of finance and payment of one care. We want to move a little closer to the mic. Yeah. And let me ask if folks find that you're not being able to hear would you just let us signal and we'll try to get the members of our co-witnesses to get the microphones closer because these both recorded broadcast. So I've been with one care for a month for nearly three years and quite a journey there. The experience remained prior to coming to one care for a month but working in the intensive care agency system for nearly 12 years. The mental health services were decided on the business and really when I was completing a career to be coming to one care it was an opportunity to take some of the payment form ideas we had on a more micro level and bring them to a macro stage. I was really excited about the opportunity to come here and this work and move it forward. I think that we've done a long way and I'm really excited to share our story. Great. So today as representative of lever in the center and realign and say we're going to focus more about one care of Vermont and kind of the governance structure as it stands and dig a little bit deeper into the finance portion of the presentation and then tomorrow we both really cover a lot of the clinical and preventative health programs as well as our quality metrics and we'll have members of our team available tomorrow to cover that portion of the presentation. So with that I'm going to try to remember both this microphone and the paper. So if you'll bear with me for a little bit I thought it would be helpful just to go back and talk a little bit about what an ACO is to provide some context for the conversation. So it's really important to stress that an ACO is a legal entity and the reason why we're held together is we have providers that can actually share resources together without losing autonomy and without having to formally merge into another organization. When these providers come together they take accountability for both the quality and the cost for the defined population. ACOs are not new and in fact they're growing fairly rapidly if you look throughout the country right now there are about 44 million individuals who are covered under an ACO construct and about 20% of the Medicare population is actually covered through an ACO. This is the way that the Medicare program is moving is the direction of ACOs and other value-based payment mechanisms. So in terms of Vermont being different in that aspect this is the way that the whole country is moving in terms of ACOs. The waiver is of course very unique in Vermont. So if I could just call out when providers are coming together and thinking about forming an ACO what are the things that they view that they need to have in place in order to be successful. So I found a really helpful slide that came from the American Academy as family physicians and they suggested that there's really eight essential elements to become successful as an ACO and of course in traditional Vermont fashion I adopted it slightly to meet our needs. So in terms of population scale we have a lot of conversations about that because the all-payer model requires us to have and meet certain scale targets as a state and of course the ACO plays a major role in meeting those scale targets because remember this is voluntary. So members that join the ACO voluntarily do so and insurance companies that contract with ACOs voluntarily do so. So that's an important thing to remember when you're thinking about having population in scale and a voluntary system as it stands right now you have to make it so it seems like something that both providers and insurance companies see value that's our job is to show the value of entering into this kind of arrangement together. At its core what an ACO does is it really provides that legal mechanism to be able to connect providers together to be able to share resources to not run a fowl of government anti-kickback or start the laws, anti-trust laws so it provides the kind of state hardware to be able to do that. We can't do any of this and you all know that we'll be offering double print reforms without primary care. We have a lot of discussions about the importance of primary care we know that there's an access problem in Vermont and I think throughout the country there's access with primary care so really what we spent the last couple years doing when we're building our programs is to think about primary care as foundational and you'll see later on in the presentation when we look at the investment streams the performance of those investments have gone primary care to stabilize that to try to stabilize those providers that are in there and I say that we've been totally successful but you've got to start somewhere. Best practices is really important to this evidence-based practices to make sure that all of our providers and sometimes this is viewed as a bad work but really have standardization so that individuals can have the same care experience regardless of where they see care and I think that's really important for people to have a similar experience with their health care and that's really the ultimate goal and to have good outcomes we're a very high value, high quality state and there's always room for improvement I believe. Financial incentives, Thompson talked a lot about that he really missed the brains along with some really talented staff and our provider network thinking about what are the financial incentives and what are the pain network mechanisms that need to come into place to really enable the clinical and delivery system change that needs to happen. I think what we've seen in the past under fee-for-service is that the system doesn't provide the right incentives for providers to really be able to practice the way that they want to practice or the way that they were trained to practice so we're trying to figure out the pain or mechanisms to enable them to do that. There's always administrative capabilities that are needed when you think about this we had many waivers that were allowed under the all data model and that requires a lot of compliance and oversight to make sure that we are really running those programs to the way that the federal and state government and the payers expect us to. As well as thinking about risk mitigation plans reinsurance plans for providers who have agreed to take on some fairly significant risk in the program and to make sure that we're financially solvent in the process. Data analysis is a really big component of it both at an individual level as well as a population level when you think about electronic medical records that really enables a provider to see what's in their four walls of their health care system and maybe they have some connections with other tertiary medical systems or with their local home health but this provides some of the data analysis that we're providing them although there's a lab because it's claims data but it does allow them to see more holistically of the care that is happening with the particular patients and the main locations. So we have a good plan for Friday. So why did the federal government do this? Why did your mom look at NACO as the approach for this all-care model? I think there's a lot of good reasons for that. Obviously I wasn't there when the all-care model came in and it got signed and some were there in the Obama administration when they decided on these skills but if I look back to the benefits that it's provided by having the ACLD the mechanism, there's multiple positive points in that this is really provider-led reform so you're asking the delivery system to provide you information about what they think is best practices in terms of them really being able to provide the best quality care they can for the patients and what do they need both frankly and financially in order to succeed in this new world that is moving quickly you can't really hide under rock anymore with pain and reform, it's coming and it's here to stay. So this is really important that they are if you will in charge of their own destiny for this. The ability to share data across multiple providers is really important so that if your individual patients say I'm meeting some care coordination services to have a shared platform that all my providers can see what my needs are, what I'm looking for what my goals are everybody have access to the same common information without having to go back to the individual and asking them by multiple providers I think we've all experienced that with your healthcare system that you go to your primary care doctor he asks you a similar question then your specialist might ask you that you're going to be a health provider so really not having to repeatedly tell that story and we all know as historians when you have an illness sometimes your recognition or remembrance of what happened in the event might not be as reliable as things go on so this is a way to really capture that information and share it. Are you going to talk about access to electronic records and information for folks who are within the ACO including primary care? I can. We have a data management discussion tomorrow so I think I talked earlier about really a forum to share best practices and if you look at a lot of the quality measures that are required under the all-payer model it really requires you to put in place the best practices in order to meet those quality metrics. They're not easy ones we were doing really well on a lot of the quality metrics though we decided to select one that were harder and that we weren't doing so well and I think that was the right move to make although it will take some more time to do the dial on those measures. We talked earlier about it's really also a mechanism to be able to share risk across multiple systems of care so that some of your small or critical access to hospitals might not be able to share this level of downside financial risk in totality we're looking at if we had the worst year ever it would be about $44 million worth of financial payback that the ACO would have to provide to all the payers that has contracts with. The positive side that could be we had a really good year that would be $44 million outside for being in a budget so it's fairly significant risk that's able to be pooled across the large set of providers and then in terms of enabling new partnerships and collaborations that's really not having to merge with another organization and being able to maintain your independence and at the same time being able to share some resources collectively with other members of the health care system this really is striving for a unified care model so regardless of your payer your insurance company that patients have access to the same care experience and that's definitely a long term goal you're going to have some misses along the way but that's the vision the opportunity to have some payment reforms and have payment structures in place that make sense and allow providers to deliver the care that they want to deliver is an important aspect. I think Ian Abakas who is the director of payment reform yesterday in health care talked a little bit about the macro events reward so it can either be a reward or penalty so for those providers that are participating under an ACO model they qualify as advanced payment and have a 5% bump to their claims for Medicare at the end of the year so that's a significant advantage for primary care practitioners that participate in this model and then I think you all know about the benefit enhancements that really seem to make sense of the way care really needs to be delivered in that access to post dischargeable visits even if you don't have a skilled need like you don't have a dressing change maybe you need somebody to talk to you about your form medications that you received and when you need to take them and do that in a time and space where you actually have the headspace to have that conversation we all know what it's like to leave you hospitalized have a new event happen and you'll be able to door all the things that you need to do while you're still recovering you all have seen this slide before when I talk about one care being provider of that I think it's important to see how decisions are made with that ACO we have a board of managers so it's to the left of the screen that currently right now it's pretty large board of 20 members so one of you who've been on board which I'm sure you all have know that's a large board to into consensus on good things we have members of the federally qualified health centers representing our board independent physicians we have all sorts of hospital systems on our board in terms of community agencies who that represents we have members from our designated mental health agency and members from our skilled nursing and long term care and then really importantly we also have consumers that represent the insurance that we have contracts with so currently we have a consumer that represents Medicare, one that represents Medicaid and one that represents our commercial insurance so three consumers on that that's our board, that's where all decisions are made final decisions remain in turn to the right we also have various committees that really are the individuals that bring up various recommendations to the board of managers to be able to make some final decisions and we have a population health strategy committee which is fairly diverged we have 20 members on that committee right now of note the commissioner for the Vermont Department of Health is on that we have Dr. Brina Holmes who works in maternal and child development I believe from the health department as well as multiple providers from across the care system we have our finance committee which Tom is intimately involved in and that really represents finance leaders from across the states and the hospitals to really evaluate some of these programs and structures that we're putting in place and making sure that it makes sense for their communities we have a fairly robust patient and family advisory committee it was a requirement under Medicare that you have a consumer advisory for this board really came together and they renamed themselves to take in an active role in looking at some of our care formation platforms and providing some recommendations we had some we were developing some four messages for one care so when people asked what is one care, what are they to we could have some common language around that and they were really vital in that conversation to say if you said that to me that was way too much to argue in it so really getting that feedback from individuals who aren't deeply entrenched in their care system like some of them was really important clinical and quality advisory committee this is a big group of people so I think there's over 40 individuals on this committee and I'm glad I don't have to share that with you but I think it's providers front line providers from around the state that are really talking about what should our clinical priorities be looking at the data making some decisions on what to focus on there's always going to be something that we should be doing there's something we should focus on and they help us to really think about what are the four or five things that are important for us really getting that information up we have a pediatric subcommittee because as we all know kids and their families have very different needs and dynamics and it's important to get some perspective of if you're developing a care model does it work for kids and adults as well so I think we've seen that we don't need to make some modifications and processes for health those are throughout the state and those are really grassroots organizations that participate with ACO as well as their local communities to think about the needs that they had and they really helped to inform a lot of our committees and priorities so a lot of work goes on and a lot of people are brought to a table before we finally get to some decisions as the ACO this process starts fairly early on so that each year as things arise we can get to some consensus so before we move to the next slide I want to pause here and see if there are any questions around the table regarding any of this the governance structure the decision making process go ahead is there any significance in the use of the word managers rather than directors the board of managers it's because of our corporate structure and that we're limited liability organizations will have a board of managers any other questions I'm going to ask a couple of questions there may be things you're going to answer later one is the risk management and how decisions are made about how to share the risk where those decisions are made and then obviously the board is going to have to vote on some of those that so is it the finance committee that brings forward the proposals for shared risk how's that so is that something you're going to talk about later do you want to just give a quick answer now that's a great question so really there's two parts the first and what dictates the risk is the upstream contracts that we have with the payer partner so we enter into a contract with the Blue Cross Blue Shield Vermont for example and that comes with our risk percentage essentially the first step is the board decides what's acceptable on that macro level for the ACO to absorb so that's one part of the equation then and perhaps more complicated is how we share that risk within our network of providers and I'd say there's no one-size-fits-all approach we have a diverse state the community is a little bit different when we first started entering into two-sided risk contracts we had a series of meetings with our basically hospital CFOs that were going to be taking the risk in the initial years of our programs and work and decided upon a methodology that we believed place the right financial incentives in place and that leads a little bit if you share risk in a certain way it might actually incentivize behaviors that we don't think are appropriate for the long the benefits are for our monitors for example referring how if you can avoid risk by referring out of your community we think that's generally a bad thing so we designed a risk model that relies in the hospitals to help get this off the ground as the main risk bearing entities and share that risk on a community basis the health service area in our state has its own measurement of their performance and that hospital is the risk bearing entity on behalf of that community and I will say as we move into the future it's a topic we discuss often at finance committee and at the full board in terms of is what we have in place today the right thing as we move forward and I think there's a a lot of conversations saying we should evolve this we evolve as an organization we evolve our risk sharing models to make sure that it aligns with our goals answer your question it does and so as a new hospital might come in to the ACO what risk model are they presented with so is it something that is prohibitive and how how does that all can I say something more just something as basic as when we're talking about two sided risk what that really means so they're clear on that so generally the way the ACO contract works is you agree at the beginning of the year on a cost to take care of the population 20,000 lives we think it's going to take 100 million dollars to take care of these particular patients at the end of the year so that's something other than 100 million most factories are getting on with this the risk corridor sets an upper and lower bound to how much reconciliation activity there is in the end so that was to say if it cost 101 million dollars to actually take care of these people the providers went over they spent too much to take care of the population they owe the million dollars back to the payer inversely if there was $99 million dollars for the savings they agreed we'll take care of the population for 100 million dollars here's your million dollars in the end to make really to enable decision making to say yeah I'll go in and do this program there are these boundaries that say the most you'll ever get or the most you'll ever have to pay is some percentage of that total cost of care of that 100 million dollars that example we enter into a program at the ACO level that comes with a total number let's say it's 5 million dollars the challenge that I think the question asks is how do we decide who is the one care Vermont network pays that if we owe it back or who gets it if we have a really good year and internally within our network we can do it in a number of different ways we really rely on the hospitals to step up and take the risk in the first couple of years of this model but as I said before I think we need to think more broadly about how we evolve that to continue to align with the policies we report and to ask kind of a strange question but for me not strange what what role of any does net patient revenue pay so each hospital has its own net patient revenue which may be outside of the money that we're talking about within the ACO so what role does that pay play yep you're asking a very good question so again around the incentives the ACO models generally revolve around primary care there are plenty of ACOs in this country that are just primary care providers and they say we think we can do our work a little bit differently as a primary care provider and manage the spend at the hospital or different acute care setting we've taken that approach and implemented it within our network so we look at the patients that attribute to our programs and where their primary care relationship is if that primary care relationship happens to be in Chittenden County then the hospital for Chittenden County UVM Medical Center is the financial risk bearing entity if that person attributes to a provider in Windsor then Mount of Scotland is the risk bearing entity what that means is that each community is locally accountable for their what it also means is that Mount of Scotland hospital has the financial risk and benefit as well for wherever that person receives their care that varies widely across our network Mount of Scotland as a small critical access hospital refers a lot more care out than the UVM Medical Center which has more services available to its patients there is a variation within our risk sharing model of how much of the care each community or hospital delivers and how much risk they have that's a really hot topic within our network does that still make sense it does put in place the local accountability Mount of Scotland is responsible for the Windsor lives that feels right in some ways but what might not feel very repair to the Mount of Scotland board or finance leadership and how the care they refer out to the Dartmouth or UVM Medical Center they're still at risk for that and there's fair arguments for both sides of that does make sense and then somebody can argue well you lose some control and so you're working on that we are working on that yes so we would like to at some point we may want to dive further into this am I correct in saying each health service area has its own measurement of performance and risk in the reconciliation process if the health service area is below performance and therefore the payer is any of that risk in any way getting shifted onto other health service areas another really big question so when we sign up at the macro level, one camera it comes with that larger number, let's say it's $5 million of risk we try to divide it up to say each community has a portion of that but the upstream program has no limit up to the macro level so let's say it's a 5% risk corridor we apply a 5% risk corridor to each community's performance for their lives so it does scale down with each community but the problem is any one community technically, let's say all communities except for one or another target and one one has a really bad year that one community could drive the full $5 million with the payer upstream so we have a pooling mechanism that comes into play if anyone community has a really bad year or a really good year once they get to that percentage that we've applied to that it's a risk limit any amount above that is cross covered with the other communities I think of it as for those familiar with reinsurance as a network funded reinsurance model if you have a bad enough year or typically a reinsurance if you buy reinsurance and kick in and protect you from that point forward you've got to pay for it it's a premium you pay for within a network like ours we can cross cover each other it will share to protect beyond that point will we be seeing tomorrow or later today in the presentation where all of this has played out over the last couple of years or is the data not available yet so where things are falling we do, it's not in the deck today we do have some information 2018 is included years there's results there I can certainly speak to it on a high level 2019 is still open we're into 2020 now takes another five or six months claims run out to have a final measurement of everyone's performance but at a high level we can speak to 2018 as being particularly for Medicare a very positive year all HSAs are shared savings which is a great start to the program Medicaid was a favorable year as well there's a two part component to the Medicaid program there's a fixed payment that is unrecognized you can either think of it as a salary either you live within it or you don't and in the year that you don't you could have earned more of the research I argue if that's good with that but there's a fixed payment measurement generally what we're seeing is hospitals accepting a fixed payment have had really strong performance we're seeing declines and the type of services we'd like to see decline it's a good thing and that's a little bit more complicated but it can be good and bad if we're trading an ED visit versus department visit or a home health visit that's a good thing so I'm happy to see fever service increases outside but we're also seeing hospitals that aren't doing a fixed payment showing some increases as well that's why payment reform is an important part of this it does change the thinking I certainly hope it continues to change the thinking so for Medicaid what we saw was we did owe some money back then in the year but the performance out of the fixed payment was better so it's a net cost in the year for the program go ahead I guess either within the corridor you need the mic so we can hear your question within the risk corridor or not are the insurers bearing some risk so the cost you gave earlier $105 million you mentioned that the other communities might pick up some of that at some point are the insurers also either taking on risk or benefiting if there's a lower good question so there's a couple ways one is if our spend were to get outside of the risk corridor the payer takes on from that point so if we had a 6% overrun and we're limited to 5% that 1% above is fully the payer's responsibility same on the savings side that's one way another is some programs have a risk sharing factor meaning that within the risk corridor a factor might say for every dollar of shared savings we earn we share that 50-50 with the payer that's the type of arrangement we have in place with Blue Cross Blue Shield and Vermont for example so if we save a million dollars we get $500,000 to reward the providers Blue Cross gets $500,000 as well to put back into the rate filing and benefit those who pay premiums on the exchange so that's another way in which the insurance companies retain some risk and reward in the bottom the last is at the beginning of the year when they enter into an agreement with us they're agreeing to a preset price and when you do that there's inherent risk is it set correctly or not and could something happen an epidemic in the state in the year that really benefits that payer or maybe we just have a really good year and everyone's helping that which would be awesome but that's a risk that they also should think about as well and the inverse side of that is the stability that offers if I'm a if I were a commercial payer I would love this idea because it allows me to take a large amount of my spend and lock it in at the beginning of the year that builds stability into their overall model Medicaid tells us this all the time there's a lot of value in setting this price up front we know for all the lies attributed to one care it's going to cost XPMPM at the end of the year that makes their budgeting a lot easier that makes the forecasting a lot easier it's really going from an hourly rate to a salary when you have that salary you know how much you're going to be paid it's easier to do your planning okay other questions? good thank you this was a great discussion thank you for all those questions so I'll be able to catch my breath I shall continue the next slide is really to just give a visual of the journey that we had since we started we all pair a skill model Kina Bacchus I think has been many of your committees prior to this discussion to talk about this sixth year agreement that we had the first year which was interestingly called year zero of the primary I don't know year zero that's when you have an unbirthday it is really Alice in Wonderland and this was the recognition that moving to a value based care system was going to take some time to set things up and I might even argue that we should have had year zero times two to be able to really get this because this is a really large scale reform this is a small level reform luckily our Medicaid partners stepped up and said we understand that in order to really develop and test a program you need to be actively implementing all the components of it so year zero was starting with Medicaid as the one commercial program and we had four provider communities at that time you can see as you move down to the map that agreed to participate and how do you design a fixed payment what is it feel like to get that fixed payment every month can we really reconcile it are there any bumps when you go to pay a claim in the process or determine eligibility within such a model we also in that year piloted a program with them to remove prior authorizations for any individual that was attributed to the Medicaid program and seeing what that would do in order to really take away some of that administrative burden that the provider's office is faced when having to call the insurance company to ask basically for permission to do select procedures and also the delays that it takes for the patient to be able to receive some care so we put in a rather robust system to be able to monitor what happens when you remove those prior authorizations do you have over utilization all of a sudden everybody's getting a CAT scan or do you because of the fixed payment this is something you have to think about do you have this like rationing or under use of services and that's going to get really important for us to monitor it's both under and over utilization of services in this type of system will you at some point be giving us what the outcome of the results are for the prior authorization yeah I can absolutely bring that in in the short we have seen that providers have not gone wild and it's been imperformed a bunch of services because of that in fact we're seeing as we measure in the Medicaid population that still has the prior authorization attached to it compared to the Medicaid population that's within the ACO similar patterns that are utilization and that's what you want that's what you want to be able to see but we do monitor that monthly we developed an application in our system to be able to really drill down if we see any variances to try to understand why we're seeing them and to make sure that it's not changes in practice patterns I think I said it to your committees before sometimes you think you say things I want to do that a lot these days it's if you're putting a provider under a budget that they have to live in just like we have a budget for the year it's really not advantageous for that provider to not provide the benefit health services routine services because you're going to be responsible for the total cost of care for that individual and if you don't provide the necessary services they can have a catastrophic amount that's going to be way more costly to your budget than if you had the home health visit if you had the appropriate screening upfront this really type of system really doesn't incentivize those preventative health and they're the big focus on that if you look at some of our measures that Sarah Barry our chief operations mom truly measuring what is the access to primary care in the ACE operation and are we seeing that go up or are we seeing that because it's really foundational and since it is foundational but since it is foundational then the measurements that you're making with fee for service as compared with the all payer the member per month and over time you should be able to measure the net patient revenue as compared with the shared savings within the system right so you can see a differential you can clarify my question for people but so then then as we look at expansion within each of the service areas you would expect to see primary care expansion and that the funds available for each of the hospitals so say there's an more net patient revenue I'm sticking with that one because it seems to be important if that goes up over time then shouldn't that be invested in primary care and what if any or community services what if any directives and guidelines are in place to ensure that that happens rather than an expansion of acute specialized care not that we dislike specialized care but if the goal is prevention and primary care then how is that how is that happening not just with the shared savings to stabilize the system but with other money funds that are there as a result of this system am I being clear or am I being obtuse I think of all and when I get into the logic I think we will show a little bit more about our investments in primary care because they are at the center of the care model that we've developed in every ECM model to be honest we talked about the funding there and then really at the highest level say that in an ACO type paradigm where you are agreeing for that preset price to be in the year the model always rewards that quality value quality quality quality let's say all is equal if you can deliver the care not in acute setting but in a community that has a different price point appropriate price point the model rewards that and if the whole state is really doing a value based care model there is no financial incentives anymore to increase capacity in acute care financially if it's within the ACO but outside of the ACO so a hospital making big bucks right so what incentive for investment in primary care or community care is there and I guess you can answer that question but let me see I don't know if I can follow up but what relationship is there between what's happening in the ACO attributed to lives and the incentives there what relationship is there at this point in the system for hospitals around their financial performance outside of the ACO and if they show a high return they're showing increased net patient fees outside the ACO is there any relationship to what's happening within the ACO is that I think that's part of what I think you're thinking I have a general answer to that I think that is this is an evolution and for communities that really in all different care product lines in the Medicaid program in the Blue Cross program they get a large enough portion of their business in a value based model where that is the primary basis for their decisions when they're making business decisions it's in spirit of value based care where we struggle a little bit more is communities just in one program for example it ends up being a pretty small portion of their business they still are making decisions in spirit of fee for service revenue, value based revenue and have a little bit of activity in value based care that's what the all payer model is if you get everybody into this other paradigm everybody doing value based care can't be effective in managing cost and quality I just wanted to follow I wanted to follow up very briefly on the example of the prior authorization with Medicaid it seems to me that that actually carries no benefit to primary care in reduction of administrative costs unless it goes across all the payers because they're still having to segment off I don't need prior off for this I do need for this, I do need differently for this so is the goal for something like that that it would be consistent for all of the involved payers, for all the attributed lives yeah, absolutely and one of the benefits that Maceo offers is the ability to take the different rules that each payer has in play and try to align the provider experience downstream so that there's a more uniform business model care model in play and it's going to take time to get there with that success in certain areas we're demonstrating the effectiveness of the provider off the way with Medicaid in hope that it can be transferred to other programs and who where will that decision be made that comes down to the contract between the Maceo and the payer so really it becomes a negotiation between Maceo and the payer to whether or not that prior authorization is lifted so what we've seen in the past is with Medicaid really as a test to see if there's always this assumption if you lift this prior authorization that you're going to have a lot of changes in utilization patterns perhaps you're going to have some effect on quality of care so that really you really need to take that out of the equation and use the data to inform that if you do this this is going to be the outcome and I think that's what we've been getting really for finding that every single year of the program and believe you for Medicaid testify in the first year that we thought it was going to be really easy to do this really it was fairly operationally challenging to take away rules and logic that had been built into everybody's system for years and years and years okay go ahead to put into context the 250,000 Vermonters in 2020 if every single Vermonter could be in the ACO plus an ACO what's the number that could be and believe the denominator don't need to directly on this it's around 500,000 maybe a little over 500,000 of the denominator that they use for a scale and that is available on every mountain airport where I'm saying I'm happy to follow up and the actual number so the waiver lasts until what year 2022 so then two more years after the 2020 and I believe that you, some of you saw yesterday in terms of where we're at right now in total so all payers, Medicaid, Medicare commercial we're at about 48% and we need to be closer 50% so less far behind this year and previous years that's really because of the infusion that we see in the commercial business this year having Blue Cross Blue Shield and as a pair not just as for the QHP population but also their foreign insured populations and their self-insured populations and there's another product that they had that's escaping me right now we also have a new contract with MEP this year for the qualified health plans and the biggest deterrent with the number that we're not hitting collectively as a state right now is around the Medicare and we're supposed to be upwards around 70% about this point in time and we're not at that number if you ask what the biggest deterrent is for providers entering into the Medicare program it's risk, it's financial risk the risk is very high in the Medicare program it's 5% in the spend on the populations if you look at their average PMTM cost for Medicare beneficiary is much higher than it is for a Medicaid in the commercial programs so all in total we have about $44 million which is large worth of risk and the Medicare program alone is $26 million so it's significant for a portion of the overall risk I have a comment and a question in my experience when we're talking about utilization the group of providers that I think would be least likely to over-utilize actually the primary care provider community yesterday we were talking about the percentage of what kind of providers in the state and the country are very different from what we've seen in Europe with 25% primaries 75% specialty what kind of conversations have you had with the community of providers that are specialists about this shifting from because the specialty work excuse me is still largely if not completely deeper service so that's a really good question and if you think about it I'm not sure what the portion is in Vermont but a lot of the specialists are employed by the hospital systems and when we put the hospitals under our capitation it's every employee that that's actually under that capitated payment so all their primary care revenue all their specialty revenue if they have imaging revenue in patient beds certain medications that would be conscribed in the hospital so the incentive is there for the specialist to be able to really work towards that value based care collaboratively with the primary care partners in that and then for the specialist outside of the hospital system that are fee for service that's what we try to do with our kind of priorities and our rather scarce to think about what sort of programs or best practices do we need to put into place and really deliver on our overall program and we try really hard last year to put into place a specialist program and we had funding available to it and we found that in Vermont at least and we go when we talk to our partners outside of Vermont and other ACOs it's really hard to put in place like one specialist program because you normally see bits of pieces like you see a little bit of EMT, a little bit of cardiology a little bit but it's not uniform so that's one of the it's a great question that's one of the things that we're really still kind of digging into to say what could be a program that could cut across all specialists because there's so many different type of specialists to be able to identify a common internal platform. One other, well I heard that this is third party knowledge specialist that has really stuck with me in that if you have to make an appointment with a specialist it's often a long way to go it takes time to get in or at least what it's going to convey to me is that it's always preferred to make sure that the people who book with a specialist really need specialty care and by investing in the primary care layer making sure that you really reach the top of the primary care license before somebody is referred to as specialist that has system benefit and that's one of the ways the whole system starts to work together is you really maximize your primary care and hopefully that has some benefit and that specialty care is more appropriate. Okay, I'm going to suggest that we move along just looking at the number of slides that are left and we'll make it stop in a little while for some more questions we'll get to the bus stop We're going to dig a lot deeper into this in day two but I wanted to provide an overview when we think about what are the successful components of an ACO and what have been some of the directionally positive things that we've seen as an ACO over the last couple of years so we've heard a lot about care coordination that's really foundation on our work started this year in the second quarter we're changing our payment methodology for the care coordination previously we've paid infrastructure payment essentially so it was the same payment all the time based on attributed lies what we're moving to since we're into a year three of the program now is paying for engagement so that's really paying for a relationship between the individual who is the lead on the care coordination of part of the care team and the patient so we've worked really hard with our community of providers I think our directors and COO spent months and months across the state last year having forums to talk to how could this evolve what would be some of the steps and safety nets we needed to put in place and we're happy to say that we've seen a lot of movement in the care coordination program and that we had close to 4,000 individuals who are actively receiving care coordination I think I've said this to this committee before but it doesn't mean that a care coordinator has called the gay owner and agreed to care coordination that doesn't count that's not actually care coordination that means that a care coordinator and the members of the team have met with me we've discussed what my mutual goals are we've developed a plan of care together and we've initiated at least two parts of that plan going forward so that's really actively having a new partnership between the care coordination team and the individual who's meeting the services so that's a fairly significant number Sarah will be showing you tomorrow and I'll just give you a little preview today when we had looked at individuals who have been under care coordination services for at least 6 months and compare them to those who are not receiving care coordination services which is harder than you think actually because we've seen a remarkable amount of churn in our population so keeping somebody consistently for 6 months has been challenging for us to monitor but we've seen significant reductions, 33 reduction in emergency room department used for our Medicare population we've seen similar reductions although not as large, 13% in our Medicaid population and I hope to have the BNA's in a further point to talk to you about the longitudinal care pilot that BNA initiated last year using some of our funding and also go to our website and watch the WCAX video that has a patient telling their story about the longitudinal care pilot and how it impacted them personally but that's going to be spread statewide this year so we're really excited to see that move forward can you at some point tomorrow perhaps, can you talk about who is prioritized for care coordination is now for every attributed life it's not for every attributed life and I'll not say or to go deeper tomorrow but at the highest level I look at it as the most vulnerable citizens that we have that have multiple chronic conditions usually we see that they also had mental health or substance use and other as I think of them social variables or social determinants as usually called to help that really impact their overall health status so we have a way to evaluate who those individuals are and provide that information to the practices puts the 4,000 in perspective because otherwise it's like right that's not a lot of people it's not a lot of people but in the context we have to have some context it is about I think 15 to 16% of those individuals are very high in high risk individuals but we'll get to those we've got many issues as well we've talked a lot about enhancing primary care we have a special program that started off as a pilot called the comprehensive payment perform pilot and that's really allowing the independent primary care to receive a calculated payment so that it can be more predictable and sustainable and enhanced to be able to cover certain care coordination services we, Dr. Joe Haddock he's in this live deck he might be in tomorrow's live deck it's really that this has been the one reform that has really worked for his particular practice in that he's embedded as a mental health person in his office to be able to see patients and we don't limit it to say you can only see an ACO attributed by that service that is available for the entire practice to be able to leverage and so having that access is quick access is really important because you know you've been in the doctor's office and here's the number to the nutritional counselor the mental health give them a call and then what happens take ready access to the office one of the things that you've heard me talk about is really sustaining medications at our medical home and community health care funding this year that's roughly $8.4 million Medicare only allows this because of the risk arrangement that the ACO is willing to take so that this money is part of our overall target so if we don't make that target the ACO is essentially funded with those programs so they're able to continue because of the work that we've decided to do together data is a big piece of it we'll talk tomorrow more about some of the data and technology that we have and one of the things I talked about earlier is really measuring the percentage of high and very high risk of vulnerable populations are they really seeing a general primary care physician or a practitioner not being engaged we're seeing an overall 6% increase in those populations which is very promising indeed and I can't remember who asked the questions but really like moving towards those what I'll call smarter care decisions and making some investments and prevention so in order for providers to do that they have to make sure that really the system that we're building is predictable and sustainable so we feel that before they start pouring additional funds into prevention work but we have seen in the hospitals have dedicated some significant funding it's close to over $30 million this year to provide additional investments in things like community mental health the home health agencies rise from our program which we'll be hearing about tomorrow because I went there and Roger she received the information that we sent yesterday and also doing things like eliminating those prior authorizations I'm not going to spend a lot of time on that idea's payment because I think my colleague Tom will spend some time with you on that I'm not going to close to this slide I wanted to bring up because we had received a lot of feedback about our transparency so what I wanted to do was share with you some steps that we had in place or put in place currently and to talk to you a little bit about some of the additional steps that we're pursuing as we move forward if you didn't know all of our board meetings are open to the public we have a public portion of our meetings as well as an executive portion as well so when we talk about things like contract negotiations obviously that can't be done in the public domain we have put out on our website we had sorry Tom don't switch we had a price water first BWC conducted an audit of our financials for 2017 and 2018 this was along with an expected process because looking at an issue of financials is there a difference just looking at hospitals financials and to be able to apply those general accounting principles to that took some time but we are happy with the results and we have been full compliance and are looking to put in some processes and procedures to move us to best in class as we move forward with the website I think I sent it out to folks prior to the session we tried to put on it quick links to commonly asked questions about one pair like what are your quality results what are your share of things there's a lot of information out there on the board site and sometimes I think it's too much information right and there's certain things that you want to have access to so we tried to just put those on there but it's certainly if you read and think about things if there's other things that you're like wow it would be really nice if we use this board we'll add that to the page and then the last thing is the green mount pair board does have all of our both budget and certification documents on that website that you could go to and find out about things that one care is actively doing the other thing that we have talked to secretary Smith about in order to you know further the transparency discussion is to explore applying to the IRS for a 501 seat free non-profit tax exemption status for one care Vermont we would be the first ACO in the country to be able to receive that tax exemption status is what I am told and we think that we have a good chance of being able to do that because the work is really in the spirit of the state's commitment to the IRS little model and that is something that we've talked about it's very unique to Vermont so we would need a letter of support from the state as we apply for that process so state to fund that and what we've said there are certain things under the 990s that we want to know in the interim we'll be happy to post those things on our website as well and then the other big thing that we're working with the Vermont care board on is keep performance Dutch boards to be able to put on our website so if you're interested in how we're doing on certain indicators we can move to that I don't want to spend too much time on challenges but I just want you to know that they exist and I'm going to try not to say that it's complicated or that it's hard and a lot of the things that we see is that tension of having hospitals and health systems that are still operating a little bit in the value based system and a lot in the fee for service and we haven't quite hit that tipping point and so they're having to operate essentially two business models so what we've heard from communities is can we go faster on this and can we get into the value based system because we believe that is what is going to work but we're not quite moving fast enough so I think that's one of our challenges how to move fast enough that it doesn't create too much disruption in the process this has been for everyone 2019 I'm glad it's behind us it was a lovely year in many ways and they're challenging and others is operational challenges with both the data and the value based payment which occurs a lot that's the message had a really tough time in administrating this disneyment for us and we had a lot of duplicate payments that were made in incorrect reconciliation that we had to work through and that makes our part for our providers to really feel like this is predictable and sustainable because I think life was anything but predictable of course it felt sustainable to them but we CMS has been, or CMS has been very good partner in this and we feel like we're on the right track they've dedicated additional resources and remember one of two ACOs that they actually have to administer this type of payment too so it's not before business the magnitude of risk exposure we talked a lot about that it's fairly significant especially in Medicare the expanding investments as the population grows so what is the right amount to be able to invest out into community agencies and primary care and to what priorities so I think that is a challenge we've talked a lot I've talked a lot of you over the summer about the really the lack of healthcare policy regulatory alignment we're still very much operating under the fee-for-service regulatory system and that's challenging the timing pressure because of it as well as reporting complications I think Senator Westman had a comment you moved offering your challenges but my comment for the challenges is we're moving all this effort away from hospital-based spending and to primary care and all of the reports we get yesterday they come into our committee and we talk that we're 70 doctors short which is if 1,800 is the number of people that each primary care doctor that means we're short primary care doctors for over 100,000 people and you want to move all the payments into primary care and we don't have the people doing the work and the medical center is only graduating six doctors a year and so I'm looking at it and I don't understand how you can't have that as a challenge and how part of your efforts are there that's a comment that was a comment thank you for pointing that out that is a really big challenge that we all face I think as responders you might want to add that bullet we're very sensitive to that one thank you okay so budget I know you've got a lot of slides to go through but we'll try to listen and then focus our questions later on great alright so budget section so what I prepared for today is not the full primary care board budget presentation but it's all sourced from that particular presentation so this is the budget we submitted to the primary care board our regulators at the end of last summer just for transparency as soon as we submit that the world starts changing and numbers move but this is that presentation or sourced from that presentation and this is my attempt to really show you how I think of one care program as an organization and it's as an entity I think there's a lot of confusion we talked just to set the table a little bit further we talked earlier about some of the ACL program dynamics how you set a total cost of care this is the other half of one care finance which is how do you make the work the machinery work and this presentation focuses on the lab alright so let's start with some really big numbers I'm a native of Monterey so I know sometimes big can be scary but let's break them down a little bit the 1.425 billion dollar number we've seen some headlines that is the total 2021 care value based budget there's really two components to that though one is 1.36 billion dollars of existing healthcare spending so these are the existing dollars used to care for Vermonters on the other programs that we enter into they're not new funds that we generate or ask for under our ACO model they exist in the system the inclusion in the budget means that we as the provider layer are now accountable for those dollars we're accountable for the cost and quality of 1.36 billion dollars to spend so increase there doesn't mean healthcare costs are going up it means the providers are taking accountability for more of this spend when you take the difference between those two large numbers at the top of the page you have 62 million dollars that's the one care budget that has two components within the first is 43 million dollars of network investment payments these are payments that one care facilitate to go right to the providers facing the patients delivering patient care programs are designed to help us transition into a value based care paradigm next we have 19 million dollars of operating costs that's really the cost of one care organization and the work that happens in Colchester even that can be broken down further it's a little bit too simple to say this is all administrative cost because a lot of that cost will show this later supports the providers direct provider support that we centrally locate for really economy we can deliver more value by centrally housing things like analytics or clinical best practice and we'll see some of that tomorrow when Sarah Barry is in and then the very last number on the bottom of the page is our gain and loss that's zero dollars we build a break even budget for 2020 and intent to operate in that fashion as we move forward okay financial flow this is a question I get a lot and it's honestly complex I'm going to try to walk through it slowly please ask me to pause your questions at the top there's really two main sources of funds flow from payers through one care down to the provider layer on the top left we have our value based healthcare cost that's the 1.36 million I spoke of a moment ago that's really Medicaid Medicare Blue Cross and we'll be moving with that as well in the top right we have healthcare reform investments that's the 43 million I showed in the previous slide those dollars are sourced from different places we have listed on the page Medicaid Medicare Blue Cross and PEP hospitals are a big contributor as well I'll talk about that a little bit as we move to the middle layer there is a split there are dollars on the left they're paid directly to the delivery system and by directly I mean the payer Medicare pays a claim directly to that provider one care never touches those dollars never closer to the one care organization however we are accountable for that spend it's part of our overall accountability hospitals and those independent primary care participating in the comprehensive payment reform practice those are the ones that accept the fixed payment FQHCs, independent primary care specialists in and specialists on health, DA's out of the network Boston Children's hospital all direct payer to provide a fee for service on the right hand side are the funds that flow through one care and really the flow through is kind of an important term here but there's two main components to it there is 472 million that is hospital fixed payment revenue so that's a payment reform initiative where we work with the payer to say turn off the fee for service reimbursement and pay us a lump sum instead we convert that into a fixed payment that every month we distribute to the hospital participants and move them off of a volume based reimbursement into this lump sum monthly reimbursement model in addition we add the 43 million dollars of health care reform investments again designed to help us do well in this value experiment so participants in the network received a share of the 515 million in a couple of different ways in the autumn left hand corner we had the hospital and the CPR practices again they received those fixed perspective payments, population management payments, care coordination program payments and the value based incentive fund is our way to reward high quality care moving to the right non attributing practices basically primary care attributes that's a general rule you can translate the acronym CBR for those who are coming which I know we've heard many times but say it again comprehensive payment reform program that's that independent primary care moving to expand that's a little touch associating primary care that's the idea so in the middle of non attributing practices that could be a home health agency a designated agency doesn't attribute what is an important player in our care model big players in the care coordination program for those who are at very high risk in our network many have relationships with home health and the designated agencies and then also play a big part of the quality score a number of our quality measures are related to post discharge care after some reason for mental health or substance use issues so the VA certainly play a big role in that and then in the bottom right corner we have non hospital attributing practices that's an independent primary care site they receive population management payments, care coordination payments by basic services funds flows I just want to be clear so you could be an independent practice and not receive CPR correct, you have this choice or you could be an independent practice and receive CPR I'll just slide 13 here so this is the full one care budget summary so when I think about one care as an entity I say we have a $62 million budget and here's how we get it here the top section is our revenue streams just like any other organization we try to get rid of different sources we have payer program investments so this is when we contract with Blue Cross any investments that they supply to us to help us along this path we have two rows for the delivery system reform DSR funding it's broken down into new program designs that we've built into the budget model and continuation of existing programs you can just see the difference there in the process of programs for our network the next row row 4 is the hospital fixed payment care coordination allocation this one is a little bit confusing to be honest but it is a payment reform where we convert some of the spend that would otherwise be deeper service claims into a cash flow that helps us fund the care coordination program there's no additional cost to the state it's a conversion of widget, deeper service based payment to a lump sum that we use to fund the care coordination program and that's in partnership with Medicaid health information technology investments this helps support the analytics platform we can't do our work without robust high quality data so that helps support that effort other investments a couple of things in this row it's actually a lot of deferred money for the prior year hospital money I'm going to show that in a blueprint funding we've talked about that a little bit as well at the end of the day it will pay for and it's going to depend on our performance in the Medicare program we have good performance that money comes to the state of Vermont through Medicare if we do not have good performance ultimately the hospitals have to write checks for that and then the last row is hospital dues it's a large number I want to talk about that in a few moments but in total that equals $62.2 million of income for one care in Vermont we spend that money the biggest portion is the $43.1 million for the population health management payments these are the programs that we facilitate that put the dollars right in the pockets of the providers the $19 million operated costs have broken down to three categories based on the there's network support regulation and general admin network support are those centrally housed functions that aim to really put resources information resources best practice resources into the provider community honestly every provider can go out and hire a data analyst we think it's more efficient to house a team of adults in one care and supply the information to them a lot of the program design same with the clinical support the regulation is the time that the one care organization spends with the screen map care board regulation and other government activities and general admin is what you think of as ordinary admin it's going to be leadership it's some of your finance accounting functions to keep the business alive insurance expenses business insurance things of that nature questions there alright I like this slide and a lot of comments as well this so I've been in healthcare finance my entire career it's a complicated space especially when you receive funds from your state because a lot of those funds are sourced maybe for federal backing as well but when I think about how the $62 million of revenue is sourced I've broken it down in this manner the first is ACO contracts with payers these are dollars that come into one care because we've executed a contract with a payer partner that could be Medicaid Blue Cross Medicare included in this is the blueprint funding if one care or another ACO does not contract with Medicare the $8 million for the blueprint funding doesn't come to the state anymore so that first row all those funds are dependent on one care entering a contract with a payer partner next we have federal federal funding with state match can I ask is that first line includes SASH SASH is included the next row is federal with state which I've worked with our partners at the state to make sure I have a good understanding of the different breakdowns that's complicated in space as well but we received in this budget model $11.3 million of funding that has really federally matched funding and the two main buckets are the DSR and the resources that we've spoken about as well as the health information technology that are subject to a federal match it's not a 50-50 split generally the match is a large portion of it is 50-50 the HIT the health information technology funding comes with a very favorable 90-10 match so that's why it's not more like a 50-50 federal state share with it the next bucket we have is hospitals that's a significant number I've broken it down to a couple different sub-buckets we have our dues for 2020 we have this fixed payment care coordination allocation I spoke of many of the go where we convert spend, claim spend into a cash flow support the care coordination program it's really the hospitals as the risk-bearing entities who are subject to that conversion and then I spoke a few minutes ago of the deferred hospital dues these are funds that we raised in 2019 entering into contracts to spend but over a number of years with providers it's a longer term demonstration projects and the last is other those are miscellaneous arrangements we have so when you look to the pie chart on the right really shows the breakdown and how dependent we are on the hospitals to fund the model the next largest chunk is the ACO contracts with payers and then certainly an important piece is the federal funding with the state match component all that federal funding of course dependent on the state match the comment I'd like to make next I was sensing some concern for the hospitals that have low risk and as you see on the slide have a large portion of the funding I share that concern to be honest and really when the elevator model came out as providers we looked at the DSR funding that was available and said great finally a reform effort that comes with some funding this isn't easy to do it take everybody in healthcare cut their teeth on fever service the whole system is built on fever service getting out of that is really hard and the DSR funding came with some optimism that we have some resources to do it early on because those dollars didn't really materialize we have some that have been really helpful the hospitals stepped up to say we believe in this we think this is the right path forward will help contribute to the cost of this ACO model but I worry about the financial burden on the backs of the hospitals right now especially in tandem with the risk that they bear so that's a consistent note I was writing to myself here is like why do the hospitals choose to be part of this and I think we need to ask the hospitals to speak to that rather than you but I think that has to do with this has to do with this we're entering into the risk clearly there's decisions that have been made that this is in their interest long term this is valuable and I think it's important for us to actually have the hospitals speak to that I think that's great I think that's great and I'd be very curious I have some ideas about answers you might hear I think you might hear different answers from CEOs and CFOs I think they generally work for the CEO but you're right all right this is a really complicated slide again this was supplied in our budget submission the New York care board a few months back the world changes and moves but this is my aim to explain this is my aim to explain some of the funding that comes through the state of Vermont to one care and then of course we use that to facilitate our programs the top section is a breakdown of delivery system reform there's a call for the 2019 amount a call for the 2020 amount and then the year to year change it's a dynamic space what DSR funded in 2019 isn't always the same as what's anticipated for 2020 and it's still certainly moving into flux so in 2019 we sourced this information in partnership with AHS we had $2.9 million to start $3 million of DSR funding that supported a small amount of our care coordination model primary prevention and rise from out within and then part of the health information technology revenue as we move into 2020 we are asking for more support in the care coordination space we'd like to continue integrating mental health supports into our model we would like to continue the statewide rollout of primary prevention programs and then you'll see that health information technology is a zero it's not that we don't want or need those funds that are shifted to the next category below so in total 2020's budget includes the $7.8 million of delivery system reform and then way out to the right we estimated the state contribution match essentially is $3.9 million as we move down we have other state investments that's the revenue line on our income statement it comes from the state of this federally backed we have our health information technology grant that's the $3.5 million and we use that to support our analytics functions because of the favorable match with the $630,000 next row the $5.3 million is spoken about that's the fixed payment conversion and then in total you see a $13.1 million number in the health care reform investments line and the $3.5 million number in the health information technology line those are carved out basically because that's the way the lines with our financial statements and the way our income grants complicated space main questions about that piece right and we hear about the match differential and so on from diva this is more complicated everything here is always more complicated that's what we do alright so this next slide here is a more detailed breakdown of our $62 million budget I want to focus mostly in the top section these are the population health management investments and we broken them down into a number of categories here some categories and in 2019 there were about 570 Medicare ACOs across the country and I bet if you surveyed them the first three rows would show just about every ACO budget I think just about every ACO has some sort of a care coordination program recognizing the need to better coordinate care across the provider types to Vicki's point earlier within a medical record you know the services that you provide to the patient you don't know what somebody else is providing to them without an ACO in place to really share that information so the care coordination I think is a very common initiative amongst ACOs next we have our primary layer these are the investments we make in primary care common in the ACO model which are built in our primary care to put resources in that layer to drive success and then the last of the standardized initiatives is a quality program with total cost of care accountability you have to make sure that you don't have any recession in quality we already have quality state relative to the nation and we want to make sure we stay that way behind the quality initiative to make sure that we remain a high quality delivery system quick question am I correct and interesting that the blueprint expenses are in that primary care line there are a lot of down below thank you and those may go to primary care practices but in terms of the initiative I'll show the next who receives these funds so the next row of primary prevention that's the Rise Vermont component this is the piece that goes right out to the networks where they for example hiring a Rise Vermont project manager for the community and these are the financial resources we supply the community to put that position in place we do have the specialty care row here pick up on some of the comments before some mental health funding as well as the specialty care program that we're really trying to roll out and advance in this next year innovation we as a diversity broad network we get lots of great ideas and the idea to put some financial resources behind those ideas was one that was met with a lot of optimism there's a process by which the network providers can submit a proposal to one care and a very thorough review with criteria that Sarah Barry can speak to much more detail much more detail manner than I can to select the initiatives that we think will help succeed and can be scaled to other communities quick question on the innovation projects are you looking for those that will sustain themselves rather than having an ongoing investment that's absolutely component measurability the ability to say did this have the positive results is another key component and then last we see the blueprint programs that the number has moved a little bit in a favorable way but this is the number included in the budget submission and then the expenses won't go over those again for the same time with those of the three different categories and you can see the pie chart to the right of our budget almost 70% flows right out to the network providers to support their work so this is a breakdown of the 43 million of slide 17 of who receives these funds so the previous slide show basically the initiative coordination for example what provider types are receiving these dollars at the top of the page and certainly receiving the bulk are the primary care providers that large number of 22.7 million dollars of investment in 2020 crosses a number of different programs you can see that on the right there's the one care we pay a $3.25 PMPM, big players in the care coordination program, big players in our quality program etc. because they're involved in so many initiatives which speaks to primary care being really at the epicenter of the ACM model there's significant funding being invested in that later and in general in terms of the access and capacity we hope that this is part of a multi-proc solution to really bolster the primary care capacity in Vermont next we have specialty in acute care significant money again the specialist program as well as quality quality award in the specialty area because it really does affect our overall performance avoiding things like re-emissions for example we have supports and services at home also known as SAASH that's part of the blueprint program the designated agencies and mental health providers $3.4 million again a played role in the learn more initiatives community health teams part of the blueprint community investments so this very provider types in here but these are investments going out to different communities to help with work and they'll say which is a different issue with parent child centers home health providers there's a 2B determined here that's really to that innovation fund we don't know who's going to win those awards yet we go to somebody and then area agencies on aging and I will note as we built the budget for 2020 we shifted from really capacity building putting the resources in place get yourself with the right resources to pay for engagement we will pay you one year acting in care managing a patient and that means that the funding here is really available for the taking but we're challenging the providers facing the patient to really engage in this type of work and we're willing to help pay for can I ask a question so quick question and then are there metrics for looking at changes to premiums maybe out of pocket and co-pays as well as for savings with the triple A's are you measuring those rate of a decreased rate for example in some of the premium costs or access to triple A services are we seeing that those changes are you measuring those changes over time with these investments which is a different a different measurement looking at what's going on with the patient expenditure is different from looking at what's going on with the primary care folks for example the answer is is that one of the regulatory pieces that might be missing at the level of the board I don't know I think it's a very complicated space when we enter into a program with Blue Cross for example we don't affect or change the benefit design but we do believe there are two different vehicles that we can help manage the actual healthcare costs for homeowners again if we avoid an ED visit that might have a co-pay of $250 again it all depends on plan design for a primary care visit that has a smaller co-pay there's savings for somebody that's complicated too because if you have 10 primary care visits and one ED then that's complicated as well but so that's one way the other way that we try to affect premiums through our program design with a commercial payer like Blue Cross by having the 50-50 sharing of shared savings the aim is that can be reinvested into their rate development model that they submit to the Greenback Care Board and lower premiums and in 2018 the first year of the two-sided risk program with Blue Cross Blue Shield and Vermont we did have a small overrun and owe them money back at the time of the 7th you can look at that and say that's bad that's the providers taking accountability and when Blue Cross developed their rate filing that was incorporated into their filing and reduced premiums that's another way in which this type of model can directly support cost to providers and patients there's a long way to go we haven't solved that the cost shift is a real thing in the state but we do look at it pay attention to it and really support the efforts that will help the cost when we look at that very long term goal of reducing the cost of health care to Vermont not just the internal cost shift but the whole thing and I look back at page 11 and say okay value based care when we include the investments towards those goals and the administration of one care and so forth 1.4 million if we were remaining with fee for service billion I'm sorry minor detail but the existing fee for service system that same care being provided to Vermonters would cost 1.6 billion so right now it looks like a zero at the end costing the same but it's actually costing 62 million more presumably the hope is that eventually that would be a negative there not a plus 62 but a negative otherwise we have not reduced health care costs for Vermonters am I interpreting that correctly yes consensually yes there's complexity within of the 62 million dollars are not new their conversion of funds that happen to flow through one care but you're absolutely right that some portion of that 62 million is an additional investment right now to help this move into this paradigm and one of our goals is to make sure that we have enough savings to offset those investments again otherwise we don't reduce the overall cost of care that's that 1.4 billion billy senator anyone have a question so I also want to get at what I think some of our constituents concerns are so of the 19 million in operating expenses 4.5 million general administration how many employees are there of one care 77 at ease in the budget 77 because you know salaries are certainly some of the things that we hear about from our constituents but the other what was my other question oh the state's portion that's the other thing we hear is there an easy way to break down what taxpayers are paying into this whole model of your budget I wouldn't use the word easy but yes I do have a breakdown of all the different programs that we offer which of those have a funding stream associated with some do some do not and basically whatever is unfunded ends up being hospital that's kind of the way our budget works as we say here are the programs we like to run here are the revenue sources we can get from our payer contracts or maybe the DSR funding for example what's left over falls to the hospitals and largely administration isn't funding through public dollars so hospitals pay the administrative salaries things like that where we do get some funding that might stay at one care it's for the like the analytics for the clinical work that supports the providers so just like any organization you have different ministries coming in different expenses you can't align them but it is a little bit of a complex space I could just add a little something to that we could send this to the committee members after we leave we do have when we think about economy and the scale so this is a centralized function absent a centralized function every provider organization because remember value based payment is here performance here would have to build these systems in their offices so when we think about what is the percentage of our operating costs we've seen a significant decline over the years so that really shows as you get more populations into the program the overall effect on the operating cost is significantly lower and we've been measuring that from 2017 to current state so we'll make sure to get you that as a percentage of the PMPM over the years okay okay I appreciate that but I'm just like I'm looking at this is this where do we get this from these handouts from Ena in the back so on this one handout it says state support is 16.6 million which is 1.2 percent of the total 1.424 billion is that I mean does that make sense to you we may have to drill down into that because there are different match types within that so yeah as you know as Tom said it does get it's not a nearer thing but this is why we got it and I'm sensitive to time I know that at least our committee needs to be in our committee room for other things and as does the House committee so I'm going to draw to a close here and thank you both very much I've been able to answer a lot of our questions and it is only stimulating more great more thinking so thank you for being here thank you very much drive safe