 Good morning everyone welcome to the Green Mountain Care Board. The first item on the agenda is the executive director's report, Susan Barrett. Thank you Mr. Chair. I have a few items. First I just want to review the board meeting today. It's an all-day board meeting. We're going to start here this morning with the ACO budget team and have an ACO budget discussion and some recommendations on the budget. We'll go until noon or schedule until noon. Then we're going to recess for lunch and then at one o'clock today we'll come back to this room. We're going to hear from the Vermont Department of Health on the state health improvement plan or the ship. So we'll have Dr. Levine from VDH and Heidi Klein presenting that plan to you today. Then after that we'll adjourn. The schedule for the rest of the month I'd like to review with folks because we have some off-cycle meetings. So next Monday we will be back in this room to hear from the ACO budget team again and we have a potential vote scheduled. And then on Wednesday December 19th we have a regularly scheduled board meeting starting at 1 p.m. and that meeting we'll hear from our partners at DEVA on the health information exchange consent policy report and then also the ACO budget folks again will be talking with us about ACO certification, 2019 eligibility verification and new criteria. I also wanted to announce that the ACO budget public comment has been extended to this Friday December 14th. So close of business Friday December 14th is the extension. Folks can comment either by phone, by snail mail, or by our portal on our website. And just a reminder for folks in this room to sign in as you enter so we'd like to keep a record of who is attending our meetings. And that is all I have to report. Do you have any questions? Thank you, Susan. The next item are the minutes of Wednesday November 28th. Is there a motion? Second. It's been moved and seconded to approve the minutes of Wednesday November 28th without any additions, deletions, or corrections, any discussion? If not all in favor signify by saying aye. Aye. Any opposed? Thank you. At this point we'll welcome the team to come down to the front for the ACO budget discussion. Okay, for the record, my name is Michael Barber, Chief of Health Policy here at the board. Just wanted to briefly introduce the other presenters. We have Kelly Thoreau, Health Care Financial Systems Analyst for the board. Michael Miles, the board's Health Care Policy Project Director. Sarah Lindbergh, self-described data geek and head of the analytics unit at the board. On the phone, I hope we have Jackie Lee from Lewis Nellis. Cool. I also wanted to just quickly recognize the other team members who put in a tremendous amount of work reviewing this budget. Marissa Melamed on the policy team, Michelle DeGree and Robert Starwalt. We have two topics we want to talk with you about. The 2019 Vermont Medicare ACO Initiative benchmark for One Care Vermont and then One Care Vermont's 2019 budget and payer programs. Instead of addressing those two topics separately, we thought it would make the most sense to talk about them in context. So we're going to start off by talking about the 2019 programs between One Care and payers. Then we're going to talk about the rates of growth for those programs, which will include a lot of background on the growth targets in the All-Payer ACO Model Agreement. And also, we're going to cover the 2019 Medicare benchmark recommendations in that subject. And then we're going to talk about risk, both at the ACO and hospital levels, followed by a discussion about the ACO budget and administrative expenses. And then One Care's 2019 programs and investments. And then finally, we're going to wrap up briefly with the next steps in this process. And I guess before I jump into this, we were thinking it might make sense to hold questions until the end. Is that okay? Okay. So this slide is showing you the payer programs that we think will be in effect in 2019. The Medicare program, as you can see, will be changing from the Vermont Modified Next Generation Program to the Vermont Medicare ACO Initiative. Under the Vermont Medicare ACO Initiative, the Green Mountain Care Board not only sets the benchmark trend rates for the ACO subject to CMS approval, but also has the ability to work with CMMI on changes to the program design. So under that authority, you know, we've worked with CMMI to develop the program's quality measures and the kind of quality withhold arrangement that you approved a few weeks ago. For Medicaid, 2019 will be year three of the Medicaid Next Generation Program. For the commercial programs, the Blue Cross Blue Shield QHP Next Generation Program would be moving into year two. The self-funded pilot with the University of Vermont Medical Center that was piloted in 2018 would be continuing, expanding to additional self-funded health plans and progressing from shared savings to shared risk, which I'll get into in a couple slides. And then there's a potential for a new TBA-level self-funded program coming online sometime in 2019. So the All-Payer ACO Model Agreement has two requirements that relate to program design. The first requirement is that only people who are attributed under a scale target ACO initiative count towards our scale targets. And a program has to satisfy four requirements in order to qualify as a scale target ACO initiative. And they're listed up here. First, there must be a possibility of shared savings for achieving goals related to quality of care or utilization. Second, the ACO's shared savings as a percentage of its expenditures less than the benchmark is at least 30 percent. And the ACO doesn't have to be at risk financially, but if it is a risk arrangement, then the shared losses also have to be at least 30 percent. Number three, services comparable to but not limited to All-Payer financial target services have to be included in determining the ACO's shared savings or shared losses. And finally, the ACO benchmark, shared savings, shared losses are some combination must be tied to the quality of care that the ACO delivers, the health of its aligned beneficiaries are both. So this slide is just showing how the existing ACO programs may be changing as we move into 2019 and how these potential changes relate to the four requirements I just went over. The takeaway here at the top is that we don't think that the changes that OneCare has discussed in their budget submission would result in a program ceasing to be qualifying as a scale target ACO initiative. In general, with the exception of the potential removal of non-specialty pharmacy from the Blue Cross program, these changes represent increasing accountability for cost and quality at the ACO. So for Medicare, you can see there the OneCare stated in their budget submission that they anticipate moving from an 80 percent gain, loss, share to 100 percent, which is where it currently is at in the Medicaid program. As you guys approved a couple weeks ago, there will be a kind of quality withhold framework in place for the Medicare program in 2019 that's aligned with other payers. For Medicaid in 2019, there is going to be an anticipated increase to the value-based incentive fund withhold percentage and a shift in the risk corridor from 3 percent to 4 percent. With the Blue Cross Blue Shield QHP program, a potential change is that there may not be responsibility for non-specialty pharmacy, which is not an all-payer financial target service, so that shouldn't be an issue in terms of whether it qualifies as a scale target initiative. And then on the self-funded pilot that's kind of expanding, like I mentioned, it's moving from shared savings to shared risk with a 6 percent corridor and a 30 percent share, that 30 percent share, meaning that it would continue to be eligible as a scale target initiative. And then the new self-funded program that may come online in 2019 is just too early to know much about it at this point, so I would accept that one carer stated it intends to develop a qualifying program there. And then the other requirement in the all-payer ACO model agreement that relates to program design has to do with alignment. So the ACO programs offered by Medicaid commercial insurers and self-funded insurers have to reasonably align in the key areas of attribution methodologies, quality measures, payment mechanisms, and services included in the determination of shared savings or losses. There doesn't have to be complete alignment, but if there are differences, we will have to justify those differences to CMS, and if we can't, come up with a plan for how to bridge those differences. And this slide is just trying to briefly set out how the existing programs may be changing in these key areas. First, for the Medicaid program, there are some potential changes to the attribution methodology that will be used. This may create a lack of alignment, but I think it's going to be fairly easy to justify those to CMS because the changes are aimed at increasing scale, and there has to be space for program innovation to achieve the goals of the model. So I don't see that as any sort of issue that we should be concerned about. For quality measures, as you guys are well aware, there will be some changes to the Medicare measures, which we've talked with you about a number of times, and those are increasing alignments of quality measures between programs. There are no changes expected in terms of payment mechanisms, which means there will be some misalignment in the sense that public payers are currently the only ones offering the all-inclusive population-based payment mechanism. So we're probably going to have to work with CMS and OneCare to better understand the issues around the hurdles in implementing such a payment mechanism. And that just is what it is. We can't make them be able to pay that way. In terms of risk arrangements, all the risk arrangements that are described in OneCare's budget are symmetrical shared risk arrangements where it's the same on the upside as it is on the downside. The levels are different between the programs, but they're getting closer, essentially. The Medicaid corridor looks like it's going to move from three to four percent. The sharing percentage in Medicare is moving from 80 to 100, which, like I said, is where it's at on the Medicaid side. And then the final subject, the final area, service is included for determining shared savings or losses. There's, like I mentioned before, the potential loss of non-specialty pharmacy in the Blue Cross Next Gen program in terms of alignment. It's not an issue. It's not currently in any of the other programs. So the staff recommendations for conditions around payer programs is really around reporting. So we want to know, we want to get a report from OneCare that demonstrates that the 2019 programs qualify as Scale Target ACO initiatives and that describes how they align in the key areas that I just talked about. If they don't align and there will be some misalignment expected, we want to understand the rationale for those differences. In terms of timing, we'd like to get that report 30 days after the end of the first quarter of 2019. And then if there are any programs executed after that date, for example, the new self-funded program, we would want OneCare to update the report within a reasonable amount of time after that. And then second, sorry, 15 days after that. Number two, you know, it's just we want OneCare to help us get the information we're going to need to prepare some other reports that are required by the all-payer model agreement, such as the payer differential report that we're going to have to submit in April of 2019. And that's it for the recommendations here. And then we're going to get into all-payer model stuff, so I'm going to turn it over to Sarah. Good afternoon, Sarah Lindbergh, GMCB staff member here to talk about math. So just to kind of apologize again for the poor color choice here, but just to reorient everyone about what we're talking about with the all-payer model, we have like this top line is over time, people who actually live in Vermont with dash lines indicating projections, so things that are not quite known at this point. Then we have for the all-payer model a scale denominator for our full population. So there's a little gap there. There are certain populations that are not included in the model, such as people who receive their coverage to the federal government or the uninsured, stuff like that. But for our financial targets, we have a further subsetting based on what data are available in V-Cures. And as you can see up through 2016, that looked pretty well aligned with the scale until that GO-Bay decision kicked in. And at that point, we really have seen a drop in the claims available for our self-funded population. So we still do get self-funded information for plans that don't have a choice about whether or not to submit, such as the state of Vermont and other governmental type plans. However, those plans don't look the same as all self-funded plans, so we kind of have a biased representation of that market in V-Cures. Then we have our scale target, which for 2019 for the full population is 50%. This is the full ACO attribution that's expected through 2019, and then the ACO attribution just for Medicare. As you can see, this is the smallest population, and for the first two to three years of the agreement, our financial targets for Medicare are just tied to this population. I'd like to bring to people's attention that smaller numbers often lead to more variability in noise and estimates, and so that it can be a lot harder to figure out the signal. So in all of these things, we'd love to see these slopes continuing to progress over time and get closer and closer to those financial populations up here, the line no one can see. And then as a reminder, while we do have some inputs that are annual that affect the way we can set our Medicare benchmark from a performance standpoint, we only have targets for the performance period to date. So that compounds over time, and right now we are looking at setting the second year. So the first year was 17 to 18. The second year will be 18 to 19. So our financial targets are the compounding growth from 17 to 19. So for the all payer population, the target we have to date for those two growth periods is 3.5% or less. However, corrective action would not be triggered unless we were to exceed a 4.3% all payer rate. Medicare is probably the trickiest thing to wrap one's mind around. And for Medicare, actual performance is never factored into the equation for our targets. It's all based on national projections. So the advantage of that is you know what your target is ahead of time. But the tradeoff is that it's hard to forecast very far down the line what those targets are going to be. But according to the agreement, we're supposed to say 0.2 percentage points below these national projections, again compounding to date. But corrective action would not be triggered for those targets unless we were to exceed those compounding national projections by more than 0.1 percentage point. All right. Not all growth rates are going to be the same. So for the commercial population, which is where the QHP bucket falls, the self-insured population, which is where the last year's pilot falls, Medicare. I think people have heard of Medicare and Medicaid. But for all these populations, there's going to be some people that end up participating in the ACO and some people that are outside the ACO. Things might grow at different rates and that doesn't need to alarm us necessarily because at the end of the day, we're responsible for all that spending when it comes to the all-payer target. So to think about how much the ACO spending is going to affect the full population, there's really two major variables. How many people are represented in the ACO? So how good is the scale? So higher scale is going to be more likely to influence the all-payer target. Secondly, the dollars. So more expensive populations are going to be more likely to influence the all-payer trend than less expensive populations. So getting more people in and getting the spending under control are kind of the keys to using this to affect that all-payer target. For instance, so if for some reason the QHP experience of the ACO-tributed population is worse and they are growing at a higher rate, the all-payer targets help us correct for that because we get to count the whole QHP population. So non-utilizers, if good risk, we're going to go to a different provider or payer, I should say. So we get all that in our target. So here we have what we're expecting for 2019. So this is based on scale. But for participation, you can see Medicare, we're expecting about half of the population to be attributed to the ACO. Medicaid, about 60 percent. And commercial-wide, we're only at 12 percent. Unfortunately, Medicare Advantage counts as a commercial plan and that's kind of where we have the least leverage. Self-funded, we're projecting to be at 8 percent at this point, which you can see is the tallest bar and the fully insured is at 20 percent. Now you have used your existing regulatory levers on all these populations through the hospital budget process. So any care they receive at a Vermont hospital, you've already had an influence over through that process. For this population right here, you've actually set the premium for these people. So you have also kind of exercised a lever on that population. For this to be a really effective lever for the commercial market and especially these guys, I think the most important way to do that would be to increase the scale. You just need more people in before you're going to be able to move that needle going back to the scale portion of how this relates to the all-payer targets. So based on our preliminary estimates, we'll definitely change. This is what we think the total cost of care is looked like from 2012 through 2017. So you'll notice that dango bay thing just causes all sorts of problems. So even though the spending is stable between 16 and 17, the population goes down. So unfortunately, when you especially are looking at anything based on the commercial market, you really can't do much trending prior to 17. And we're working for ways to correct that. Unfortunately, it's a little bit hairy to take out the people that are either voluntarily submitting or don't have the option to not submit in that self-funded market. But we're trying to get a more apples to apples comparison prepared. But assuming this estimate, so that would be a baseline all-payer target of $496, which puts the per member per year just under $6,000. So if we can pound that forward to 2022, the all-payer target would be just under $600 per member per month and just over 7,000 per member per year. As a reminder, these do their best to include a claims-based portion, which is based on that V-Cures population, which is why go bay causes problems, and then a non-claims-based portion. So for the non-claim spending, we're trying to align it closely with Medicare. So we're looking at the blueprint for health payments, community health team payments that payers are making. And then as any non-claims-based programs might start up, we're trying to capture those information from the payers. So for instance, if you decide you want to pay for a joint replacement in a bundle or based on the episode, that might not go through a claim. So we just want to capture that kind of spending. And the other really important point is that these numbers are going to be different than anything you see in the contracts with the ACO because we feel really strongly that we need to base it on the allowed amounts instead of paid amounts. So paid amounts make sense when the payers contracting with the ACO because that's the insurer's risk, that's what they're on the hook for. However, when you talk about the actual spend, there's what the insurer pays and the member's responsibility. And we don't want to set up an incentive for spending to look even because you're shifting more and more costs onto members. So that's why we are just focused in on that allowed amount for the primary payer. And the reason we focus on the primary payer is that we don't want to count spending twice. So for instance, if I have a commercial plan and I can't, you know, I've also qualified for Medicaid, Medicaid is going to chip in as a secondary payer to help me with my member share amount. So if I were to count all the spending, I would be double counting things. So by counting the first payers primary allowed amounts, we're trying to get the best estimate of the actual spending. Anybody bored yet? And so this is just focusing on that total cost of care population. So again, this is not the scale population. This is just people in V-Cures. And if you'll see the, you know, the go-bay dip again, but where we are here for the baseline spending, you'll see that about half the population is commercial. And the other half is pretty evenly divided between Medicare and Medicaid. Another reason where, you know, our biggest contributor has the least scale. So it's really important, again, to try and get more commercial business into this thing to make it an effective lever. So this shows the bottom line is, so now we're switching just to Medicare and we're looking at the total cost of care, but these are paid amounts. So this is just focusing on the insurer pay, what Medicare pays and does not include the member's responsibility. So Vermont continues to be below the United States in terms of its growth. And underneath, you can see kind of these historical annual growth rates over time. And I think what freaked everyone out was back in 2015, Vermont grew at 4.3%, whereas the national grew at 1.6%. But we have not seen that trend so far continue. Vermont's been pretty close to the national trends as a statewide number. But also, you know, smaller numbers, more variability, there is always a chance that we could have another 4.3% pop up. So this is showing what the national projections, where do those come from anyway? So just for the setting the Medicare benchmark, we do have to look at something that people refer to as the call letter every year. And this is something that is sent to commercial insurers as a way to help them set rates for Medicare Advantage plans. So they include the experience of the fee for service population for commercial insurers to base their estimates on. So they produce them for the aged and disabled population in the ESRD. The reason that we divide this up into these two populations is because while these aren't a lot of people, they're a super expensive population. That kind of helps prevent too much mischief from the noise that we would expect to see from smaller, expensive populations. So back in April of 2017, they said, well, you know, given the information we have so far, we think the PMPM for a typical Medicare member is going to be 825 bucks a month. And we think in 2018 it's going to be 848 bucks. So that would be that growth rate of 2.8%. But we use 3.5. That's because we used a convention in the agreement that allowed us to use what we call the floor. So we were able to use that 3.5% and be held harmless from what happened. So if we hadn't used the floor, we'd be basing the benchmark last year based on that 2.8 for the aged and disabled population. However, this April, in April 2018, they said, you know what, basically we've got better information now. It turns out we think that the PMPM was closer to 833 bucks last year. And now we think that in 18 it's going to be closer to 850 bucks. So we, you know, we got it a little bit wrong. We're going to adjust it upward. And now in 19 instead of predicting 889, we think it's going to be 891. So in other words, given the best information they have to date, they think the growth between 18 and 19 for the national Medicare population will be 4% for the aged and disabled, 3.3% for the ESRD, which blends to that 4% in the population overall. So that's where 3.8 comes from. So according to the agreement, we can only set our rates at maximum to be 0.2 percentage points below that estimate. So the 4% growth rate for aged and disabled, you take off the 0.2% and that's the 3.8. And stage renal disease is 3.3. We take off the 0.2 and we end up with the 3.1%. So again, just this is just projected growth. Actual of the observed values nationwide may vary, but that is what we're on the hook for when we're looking at it. But that annual estimate is only important when we're setting the benchmark for the ACO. When we're actually held to accountability for the Medicare total cost of care right now, our target is a combination of the growth from 17 to 19 that we're projecting. So if you stick in the 3.7, which is the floor, so that's the 3.7 minus the 0.2 gets us to the 3.5. So if you stick in that floor estimates is the first term, put in the projections for the next year, that means our target compounding 17 to 19 will be 3.7% for the aged and disabled and 3.3% for the ESRD, put them together, what do you got, 3.7. So it's always going to be really heavily biased towards the aged and disabled because there's so many more people in that population. So where do we think we're at? We think we're currently would guess that we are at 1.1% if we're looking at our growth assuming that the 3.8 is realized. So I can walk you through this step by step before we get there, but we think that we're going to see an actual decrease in PM, PM from 17 to 18 in our national actual observations. And if we assume that the whole population would grow at that 3.8, that would mean our performance to date would be 1.1. So again, the target is 3.7. We think we're subject to change, but based on the best information we have so far that we would estimate we're currently at 1.1% growth. Again, that's statewide, not just the ACO. So here we go. So again, for the performance years, early years and one and two for sure, our financial targets are going to be tied just to the Medicare people that are in the ACO. So the way we come up with this estimate is the actual ACO spending that we won't know until about the middle of 2019. We'll know what the actual spending in 2018 was. We compare that to what we think the spending would have been in 2017 based on the same set of providers. So what it actually came in at and then this fake year basically. So we're trying to figure out apples to apples as best we can how the growth was. And so based on best estimates to date, these are the per member per year costs we think we're going to see for 2017 and the range that we might come in at 18. The range represents the end points of the potential shared savings. So if the minimum savings were realized and the maximum savings were realized that we would expect a 1.5% growth rate for the age and disabled and quite a substantial decline for the end stage renal disease, which is an overall decline. These numbers will change. Especially the ESRD claims tend to have take a longer time to complete. So don't put these on your blog quite yet. We want some more information before we sign up for everything. But based on claims paid through June with run out through September, this is our best current estimate. All right. And then you've heard enough from me. We'll turn it over to Jackie, right? Yeah, Jackie, just tell me when to click. I'm trying to get back to what Sarah was just talking about. This is from the call letter, the 2019 call letter. And one of the things that we were charged with doing was determining whether or not we basically agreed with CMS's projection and kind of comparing that back to what one care has put into their budget. So I had pulled a piece from the call letter. You can see the blended CMS US cost per capita there at the top starting with 807 in 2010. This is updated each year in the call letter, which is released in April and has projections for the future years. You can see that going all the way down for the population. And one thing to note, this is a blended figure. What I mean by blended is it's blended of the aging, disabled, and the ESRT. So as you're kind of flipping back and forth between other parts of this presentation, especially of what Sarah just went over, she flipped it out. But here it's blended and it's based on the enrollment. One thing to note that the ESRT, while expensive as you've just seen, is between 0 and 5% of the total population from a nationwide perspective. Then we took a stab at deviating a little bit from, in that second chart, deviating from the CMS approach they obviously have much more data and more sophisticated processes to come up with their growth rates. But one of the things we talked about last year that I didn't go to outline this year because I think we hit on it last year was that CMS is not always right in these projections. And so based on that, we took a little bit different approach using historical experience that we see here in the growth rate of the top chart to come up with two separate growth rates. So we've got the CMS numbers of 4.63 and 3.7%, and then we've got our projections that are both in the 3.16% and 3.13%. So to kind of get back to, you know, what does this mean to us? As we roll forward to the next five, we've got our, as we take the blending of those numbers from 2017 to 2022, you can see we, CMS's national target is 1., sorry, 4.01%. Over that time frame, so that would be the national target, then we would have to take the minus 0.2% that I know she's just spoken about to get us a Vermont target of 3.81 if we believe CMS is projection. Utilizing our projection, it takes it down a bit. So it makes the target to be a little bit more aggressive because the growth rates are lower at 3.54%, taking out the 0.2% to get 3.34%. I've also shown it graphically below to kind of show the deviation. The one good thing about this graph is that if you compare it to last year's graph that we had in the presentation last year, the gap between CMS and L&E was much greater. And so what's really happened here is that CMS's numbers have come down being not exactly in line with what we projected, but it's definitely a closer representation and they do end in 2022 being a little bit closer together. On slide 25, I have kind of just a scenario to throw out to you, a couple scenarios to throw out to you guys. I think given last year having such higher growth trends that CMS was projecting, this added a lot more color because one thing we were very nervous about was the fact that they were asking for some pretty high increases relative to the national target and then ultimately the Vermont target. And so in last year it was really where there was a really high number in year one which would have been required a few two years to have a much lower growth rate. We also know more now and we know that as Sarah just went over I believe it was a 1.1 is where we're sitting at versus let's say if we were sitting at four and we had to drag that down over time. So basically what this is saying is that this CMS target, the target is 3.81 which is the bottom figure and L&E's target is 3.34. Basically what I've done here is shown some scenarios to say that okay since we had 3.5 in 18 and they are requesting 3.8 in 19 what does that mean in 2020, 2021 and 2022 that we could approve? So from a CMS perspective as long as the trends aren't going up we should be able to hit the target because we've had we had a favorable request in 18 plus we're having favorable experience. For our projection it does require a little bit of deviation where there are lower trends in future years in order to hit the 3.3 but this is more just informative and illustrative so that you can wrap your minds around what potential implications could come from approving a 3.8 percent. That does mean that their trends might have to be lower in the future which I'm sure most of you understand but I wanted to just kind of put that out there. All right, Sarah you get to talk about your complicated formula now. Oh I get the joy of this one. So this slide is showing the 2019 Medicare benchmark calculation and as you can see the overall benchmark for the ACO is really comprised of one benchmark for the aged and disabled Medicare beneficiaries and another for the in-stage renal disease beneficiaries. To calculate those benchmarks CMS estimates the 2018 per beneficiary per year spending for those beneficiaries in each category who would have been aligned to the ACO in 2019 based on the 2019 provider list which is a mouthful but it's basically the hypothetical population based on the ACO's providers in the performance year looking back at the year prior to the performance year who would have been aligned to the ACO and what are their costs and then you multiply those numbers by the number of beneficiaries in each category that are actually aligned to the ACO in the performance year so 2019 and then finally you multiply that by the trend factor or trend rate that's set by you and approved by CMS. So we've got kind of the calculation in words and these are the numbers that are going to be used to plug in and we've modeled here the ceilings that you could approve that Sarah talked about so the three basically three eight for aged and disabled and three one for ESRD and then the box on the far right reflects an adjustment for the ACO's shared savings in 2018 so initially this gets a little complicated but initially CMS is going to use an estimation of shared savings so 6.1 million and then multiply that by the blended 2019 trend factor that the board approves which we're modeling here as the 3.82% and that's 6.1 million dollars represents 80% of the approximately 7.7 million this year for blueprint and sash so that's going to be used initially for that kind of shared savings adjustment and then once the 2018 settlement is finalized and one cares actual shared savings or shared losses are known then the benchmark is going to be adjusted to reflect those actual shared savings or losses so if one care ends up performing really well and saves the maximum amount which we think is about 16.2 million dollars then the benchmark is going to increase if they save less than 6.1 million dollars then it's going to go down and then this slide is just showing a high level comparison between 2018 and 2019 benchmarks and I think it makes sense to go from the bottom up so looking at the bottom the total benchmark for 2019 assuming the 6.1 million dollars for shared savings and assuming those trend rates of 3.8 and 3.1 the total benchmark would be a little over 581 million dollars which is a 44% increase over 2018 but looking at the middle rows you can see that it's not a great way to measure ACO growth because the number of attributed lives is going up by 50% and then going up to the rows at the top you can see that on a per member per month basis the benchmarks are actually going down by between 5% and 6% and the difference between the 5% and 6% is the minimum and maximum shared savings for 2018 so that 825 p.m. p.m. figure is assuming 6.1 million and the 840 is assuming the max of 16.2 for 2018 another point I just wanted to make here is that that 581.7 million dollars that would be the benchmark assuming these inputs is like the other total cost of care targets in one care's budget targets for spending on ACO attributed patients the money is not as you know all flowing through one care some of it is some of it's flowing as all inclusive population based payments from CMS and Diva down to one care and then out to providers a lot of it is flowing around one care directly from the payers to providers as typical fee for service payments but one care maintains responsibility for those dollars so it's a big number but you know it's the cost of caring for patients it's not you know profits or anything like that so so that's that's that our recommendations are here on this slide so the staff is recommending that you approve the 2019 Vermont Medicare ACO initiative benchmark for one care using trend rates of 3.8% for the aged and disabled component and 3.1% for the end stage renal disease component you know these rates are within the parameters set by the all-payer model agreement and as Sarah explained based on our best estimates and the best data we have available would not cause us to exceed the Medicare growth target to date we also think that savings generated in early years of the model could help offset the additional risk that would come with increasing scale in the model or allow for investments in care transformation without putting additional pressure on commercial rates and then finally you know the high levels of risk in the Medicare program I think as you guys have heard have kept some hospitals from participating in that program and without the hospital in the program and accepting risk providers in the community are by and large not able to participate in the program either so we think that early successes in the Medicare program particularly could help increase participation in their forescale okay Jackie I'm going to turn it back over to you we're on slide 29 slide 29 yes so we are in the process of with Diva we have received data from weekly we're in the process of reviewing that to make our recommendations you will receive a report from us on recommendations that we have for weekly and for their consideration before that rate can be finalized unfortunately this information is confidential because the negotiations are ongoing so far based on our review as we're writing up the report weekly's range for growth will fall within the recommended range and our best estimate that we have come to over the last week moving to commercial QHP on slide 30 recently the negotiations are ongoing one here and we probably show Vermont for both 2018 and 2019 one of my biggest concerns regarding the 2019 you know proposals we've seen a few of them although none of them have been finalized formally at this point but one of my concerns so far is that when they were floating figures in the initial submission it was not consistent with the board's order during the QHP filing additionally we have two recommendations the first being that they blanketly took the trend figures from the commercial QHP rate filing we don't think this is appropriate if you head back a few slides and you look at the percentage of those attributed to the ACO from this market it's roughly 20% that is a really small subset and this population due to the attribution process has different behaviors than those that are not attributed such as you have to have a PPP visit which means that nonutilizers are not ever going to be a part of the ACO under the attribution process so they just will exhibit different behaviors and trends so we recommend that those trend figures be developed from that population utilizing data that they should have available to them the final recommendation is another one based on our observations from the note above is that one care was utilizing figures within their initial submission that was not not appropriate meaning that I know that the pharmacy is not covered under this yet they were using a blended trend figure so our recommendation is that they use glue process final filing we do references to it and that final filing was based on the board's order that's a really helpful process that we have in place in Vermont is that after the order comes from the board each of the carriers submits a new filing with those rates supported based on that order and we recommend that be referenced within the initial submission the L&E report was referenced on a different basis because it's from the unified rate review template or UROP and so we just want them to be more mindful of the figures that they're using because we felt like they were misrepresented within the submission itself moving to slide 31 we agreed with the staff recommendation to approve the Medicare benchmark trend rate of 3.8 which was requested by one care we believe that our recommendation will fall within Lake Leeds Range for Medicaid of which we cannot speak to quite yet publicly and then for the commercial QHP I just outlined two of our recommendations that you can see on the prior slide one final recommendation that we have is really in regard to the overall one the targets that are set we really don't believe in as our responsibility to ensure that the two parties between the pair and one care we don't believe we are part of that process that they're negotiating we can offer up recommendations and then evaluate those agreements but we're heavily relying on the actual expertise for teeth at the table as well as those other professionals one recommendation we have is that one care provide an actual certification for the commercial benchmark really just to ensure that they are adequate but not excessive we spoke in with one care and they seem to be an agreement that they should be able to obtain an actual certification and this would give us comfort that their actuaries are involved and have truly assessed the risk of these target figures the next thing we recommend is that one care provide the board with how the each of the targets builds up to the overall rate of growth across all payers and how that fits in that are part of the all payer model ACO agreement because we don't have agreements across all the payers that was not something we could easily assess so we would really encourage the board to require that just so that we can know that they are on track with the requirements within that agreement and then finally we think that the board should see a revised budget then smart tips and final life so that you can get comfort at all of your orders and all of the recommendations that were made were probably more effective here's a hospital on their desire and right now they are this slide here shows the risk by hospital by payer see Medicare, Medicaid the Blue Cross QHP three hospitals for which they are mitigating risk as well as at the very end the estimated MRL this table here shows by hospital in HSA the MRL we went ahead and took the day's cash on hand from their 2019 approved budgets and translated that to how many days cash on hand the MRL is equal to and then took MRL down at the end here Pro Jackie's recommendation we made sure that all the hospitals are under 5% which they are once we do reach 5% as we move further into the all payer model if hospitals are taking on additional risk and we go over then we do need to reevaluate how this is working one item to note on the previous slide number we received the Medicare benchmark earlier this week and that number there goes from 23 million to almost 30 million dollars what we did do to make sure that the hospitals are under that 5% for their MRL was assumed that they were allocating proportionally to those hospitals taking on Medicare risk and reran the numbers and no one is over that 5% mark you guys are heavily involved in the budget process we have I think influence or insight information into the risk because you're taking we also look at a few other metrics such as the current ratio and what that MRL was like a percent of revenue and one of the things that we need to really focus in on the data cash on hand is that it took into account their other obligations so looking at just the revenue I mean again it's all very small features sort of a chart as you put across the hospitals so my concern was we didn't know what the next thing was what activities they had outside of that where the data cash on hand does really help and they have out there so a 5% I showed was because none of our hospitals did that at this point and they come see back from one care and look at the financials so far the risk they've taken on over the past couple of years has not impacted the needs of the financially so I felt like looking to then create that next way to go about it and again if we have a hospital that approaches or goes above the side that doesn't mean that they're necessarily in nature I just feel like a good point let's keep this as low as we can for now and then start to assess that more going forward but I think this would be one of the best measures we can have from the available from that hospital that could be monitored and that is something that our hospital budget team will continue to monitor throughout the hospital budget process so moving on to staff recommendations we want to we recommend that the maximum amount of risk the one care may assume for 2019 is the sum of the 5% of the Medicare benchmark 4% of the Medicaid benchmark across Bushield QHP benchmark and 1.8% of the commercial self-funded program benchmark we also recommend that one care request and receive an adjustment to its budget prior to executing any contract that would cause it to exceed those risk levels we also recommend that one care provide the board contracts with the hospitals who are taking on risk that one care hold at least $3.9 million by the end of 2019 and that one care must inform the board whether it has secured aggregate total cost of care protection for Medicare or any other payer in 2019 Jackie anything else on the recommendations moving on to the budget administrative expenses so you can see here the operating margin and total margin there really hasn't been much as far as those two metrics go in 2018 through the budget order you approved one care hold reserves but we didn't indicate where specifically it needed to hold those reserves therefore we've got this 0% operating in total margin when you look at this 0.3% operating in total margin in the projections and the submitted budget for 2019 that 0.3% is strictly the reserves which are currently falling to the bottom line when we move on to the administrative expense ratio we can see that it's actually decreasing from the 18 approved budget to 18 projection it's up a little in the 19 submitted budget but that's also taking into consideration that one care has incorporated programs increased FTEs for those additional programs that they're offering that ratio and current ratio remain somewhat constant as far as staff recommendations in this section in the same way as last year we recommend that one care's administrative expense ratio must be consistent with its proposed budget if the expense ratio increases by more than 1% inform the board also in the same same way as last year we recommend that one care insurances administrative expenses are appropriately allocated by state and then finally that one care must submit its audited financial statements as soon as they are available and must submit information as required by the board to monitor performance and last but not least I'm going to speak about the programs and investments on November 14 let me switch slides on November 14 when we presented to you we reviewed the population health programs and investments and as you will see in 2018 they had budgeted 27 million and in 2019 they submitted a budget with $37 million and this increases through the attributed lives in the addition of new programs not working okay so the state is receiving continued funding through the Medicare next generation program to continue their support of the multi payer advanced primary care practice demonstration started by the blueprint for health so one care has budgeted dollars to continue the patient center medical home legacy payments CHT and sash expenditures at a 3.8% increase over 2018 budgeted is the Medicare benchmark growth trend that we recommended earlier and that one care is requesting for 2019 this is a list of the new population health program investments and we did review these in detail on November 14 they're expanding the comprehensive payment reform program for independent providers to participate in a capitated model and we are also going to monitor and examine the specialist program which is going to allow one care to focus on population health quadrants two and three which is the rising risk population they're expanding one care rise Vermont they're also working with VDH to pilot the Dulce project which is currently in one community and they're looking at expanding that to three communities and then finally they've budgeted for an innovation fund they're planning to issue at least one or two cycles this year for communities to test and spread innovations to communities so we reviewed these earlier these were all budgeted in their 2018 submission and they are continuing in their 2019 submission so finally we have a number of staff recommendations for conditions on their programs and investments number 12 is the payment reform investment ratio and blueprint funding we are recommending that one care fund the population health programs at no less than 3.6 we are allowing a 0.5% variance this year because there could be ramp up with new initiatives we recognize that so one care must also fund the CHD payments for health at the 2018 Medicare level plus an inflationary rate of 3.5 in risk and non-risk communities we're asking them to follow up on the 2018 CPR pilot to provide us a final report comparing the 2018 quality outcomes of the pilot with a non-pilot cohort analyzing how the payments compare to payments hospitals are making to primary care providers not participating in this pilot and describe the practices experiences with the pilot if they have experienced a reduction in administrative burden we would expect this report be submitted in the fall of 2019 which would allow for claims run out similarly on the expansion of the CPR program in 2019 one care we've asked them to provide an interim financial report by July 30th 2019 to describe changes from 2018 to 2019 with an analysis of how the payments are received by the practices under the pilot to payments hospitals are making to primary care providers not participating in the pilot we received a similar report last year we have we've requested a report for the by the fall of 2019 that one care described their progress toward a new distribution methodology for their value based incentive fund that they are projecting would be implemented in 2020 and then finally we would like a report on the community to monitor the distribution of the funds and we would like to work with one care to understand how the innovation funds are balancing a statewide approach while considering regional community needs so next next steps like Susan mentioned we've extended the public comment period through the end of the week which is as far as we can go if you're voting on Monday we will come back on Monday and do any sort of follow up that we need to do with you and then hopefully get some votes from you on two subjects so first our recommended approval of the 2019 Vermont Medicare ACO initiative benchmark for one care going back a number of slides now just a reminder we're recommending the 38 for the 3.1 for the ESRD component and then the second vote would be on one cares 2019 budget and again we're recommending that you approve that budget with conditions around rates risk reporting investments administrative expenses and all the 16 conditions we went over and that's it for us happy to try and answer questions other questions from the board I have some questions I'm wondering Kevin do you want me to go through my questions are sort of span multiple topics do you want me to go through all the topics or do you want to do it by topic go through all the topics okay take it away all right okay I'm going to do this by slide number so on slide 11 and this is more of a comment than a question I just thought it was important to really remind all of us where the 3.5 to 4.3 range came from which was when the agreement was being negotiated there was a lot of analysis on Vermont's statewide economic growth and that range is based on different periods of time with the goal of course of bringing healthcare costs which historically have grown faster than the economy closer in line if not in line with the states economy and again the thinking there was what we've seen in the past is that as healthcare costs grow faster that's created wage stagnation as employers put more money into the healthcare costs rather than into wages so that's really just a comment that's easy as we delve and do our due diligence in the weeds to lose sight of the forest and the big picture so I don't expect you to respond to that but I did just want to make the context is helpful good I also wanted to comment that I found slide 13 very helpful because I think as we are pursuing this regulatory process of reviewing opening context of the overall goals of the agreement and our regulatory responsibilities on a statewide basis which obviously go beyond as Sarah mentioned just this regulatory process into the hospital budget and our rate review process so for me personally it was very helpful to understand the commercial attribution is being just at 12% in terms of understanding how the ACO program fits into the larger context of total cost of care generally because quite frankly it seems to me that at that low in attribution level the commercial rate could be even higher than what we approved in the QHP filing and and really have no make very little difference until we get more scale in that program on the total cost of care and that assumption in my thinking to make sure that I'm on target and you can correct me if I'm not on target no I think we've discussed that at great length whether we can you know what do we do with without the parties being close on the commercial rate and you know I think the answer is in terms of our targets we're responsible for Medicare and all payer in terms of the all payer target it's not going to be just that we want to recommend to you and I think that focusing on having a rate that's actually based and actually sound is one and then two giving you know Jackie had some recommendations around what data to use and so on but just giving the parties space to reach an agreement that makes sense for them and they're both willing to live with or the two kind of primary things we're trying to trying to get to with our recommendations thank you that's very helpful then next slide 14 I just wanted to restate your what you said Sarah around why you why you think allowed is important in slightly less technical language to make sure that we're getting it which is that allowed makes sense because in addition to the health care bill that the commercial insurer or Medicaid or Medicare it also includes co-pay co-insurance deductibles and you wanted to ensure that there wasn't an incentive for the payer to increase that cost sharing in order to fit within a target so is that a plain language is that plain language summary okay that's what I was trying to say you said it just in a technical way that I wanted to make sure you good on slide 16 which is the Medicare total cost of care paid amounts over time I I wanted to note that I'm I'm glad to see that Vermont is no longer growing faster than the national growth rate which was as you mentioned a major concern during the negotiation with CMMI because of course we were worried about agreeing to a target which was below national if Vermont was growing faster so that is very comforting to me that we seem to be becoming more aligned there so I'm skipping out a slide 25 which is one of Jackie's slides but just in general relating to the different calculations and analysis that you provided related to the Medicare total cost of care for beneficiary growth estimate it was very helpful to me to have both kind of the projections at the ACO level but again because scale matters in terms of how the ACO program fits in with the total Medicare cost of care it was very helpful to me that on slide 20 you gave us the bottom line which is that in terms of the total cost of care growth at 1.1 which is well below where we think national is headed and exceeds our performance target of 0.1 below so I think it's very easy for those of us who are not sophisticated math people which I would say I myself am not a sophisticated math person to think 3.5 means 3.5 means 3.5 but that's not actually how it plays out so I very much appreciate you giving us your best estimates to date and putting it in a context so that we can understand how our decisions today relate to the overall total cost of care estimate so thank you for that on slide 27 this slide I think was very helpful in terms of understanding the total dollars scale and the PMPM and ultimately it's the PMPM which matters most in terms of our agreement and judging against the statewide Medicare benchmarks and of course in health policy there's the old adage that bigger pools are better because just like with data it adds stability and reduces volatility of experience and I think this slide is very helpful to show how that plays out in terms of the PMPM actually being reduced even though the total cost of care is increasing and the population is increasing so that was helpful to me to be able to look at this and understand that as the Medicare attribution has grown the PMPM has actually been reduced because the population has changed and we have a greater variety of health in that population and again correct me the meaning I'm saying doesn't make sense because part of what I'm doing is just making sure that my understanding of what you articulated is right I'll let you know thank you okay so just jumping to the commercial QHP which is slide 30 so I in terms of Ellen's recommendation that the trend for the commercial rate be developed using the ACO population Jackie it was helpful for you to articulate that currently we're thinking the attribution is only about 20% which is a very small subset of this population and has different trends so the way that I interpreted that in sort of plain language was that we would expect given the way attribution works that the healthiest people would not be attributed and therefore the ACO population should we would expect have a higher trend than the overall QHP filing amount that we approved because we're really just looking at a subset and the healthy people are less aren't going to get attributed so if that thinking is not if that plain language thinking is wrong Jackie please correct me but that's how I interpreted what you were saying there just well go ahead Jackie sorry so yes that's accurate one thing to know as that is within my draft report is that because the subset's small we may have credibility issues which is what needs to kind of couple the point to they may need to end up utilizing a little bit of that the whole group because that's how you're going to figure a trend going forward but that's absolutely in line with how I think about it though I should caveat it and say I do not have any data that is ACO attributive population specific for the commercial QHP so it very well could not be the case but your logic is the same logic I have okay thank you and I would just clarify that while health maybe one reason for utilizing there may be other reasons that people don't have claims but it's certainly a different you would need to utilize to be attributed thank you sir I'm almost done on the programs and investments so this is slide 41 again this is a forest for the entries check in I was happy to see that the 19 submitted in terms of the programs and investments that the dollars had increased because one of the goals I think of the ACO program from my perspective was to find a way to shift dollars from hospital spending to primary care designated agencies home health agencies other community providers and to prevention programs and given that there's an inclusive population based payment that's taken off of the hospital spend to reinvest into these other programs I was I'm pleased to see that that at least appears to be growing because I do think that that is has the potential again it's early years but it has the potential to shift our healthcare system in more meaningful ways now obviously in our current scale that may not happen but because of the results but I was pleased to see that that was growing and thank you also for reminding us again that this is now our way that we're able to continue Medicare's participation in the blueprint in terms of your recommendations Melissa when you spoke to this is 45 to recommendation 12 verbally you said you were recommending this as 3.8 so I just wanted to clarify what your recommendation 38 yeah okay I thought probably 38 it was just a yeah yeah it's just a yeah there's a lot of numbers in this whole thing that are very similar I just wanted to make sure the record is clear more than anything else and then lastly on 16 I appreciate this recommendation very much I think that amount of Scutney hospital and we heard from the Windsor community we started to actually get a flavor of how some of the community investments were flowing through at least in that one community so I like I'm glad that we are that your recommendations include follow up reports on the new programs which quite frankly doesn't give us necessary for us to try and understand how things are flowing through at the community level as well okay other comments from the board Tom so I have a few here but I'm just trying to make a connection between budget document that's submitted by one care and going to slide 26 and I'm just going to have some connection on slide 26 it talks about the 2019 benefit areas but the ACO at $58,575 in the budget document their attribution number less yeah it's less yeah $4,398 so that's a big spread well the first one is one care estimate at the time and this one is the actual numbers based on what CMS has run in their system and it's really important to note that not all $58,575 people are going to make it to January one so a lot of them ultimately will not attribute so the actual attribution number will be less than this I think it'll still be higher I think than the ACO but not not quite this different yeah thank you the next one is the slide 39 my specialty known right at the time and as I read this the number nine here it says that the increase by more than one percent and I'm looking at the percentage of the administrative expense ratio that is calculated from the budget documents and it's 1.77% so as I read this which could be a total of 13 that it could go to 2.77% there seems to be a very large margin or a large flexible buffer around that administrative expense and I'm just wondering am I reading that right that one care could actually have an administrative expense so 2.77% and we don't have to report about that that's correct we do receive quarterly reporting so we do see what that is ongoing I think the flexibility is there as we as they begin this business I mean worst case scenario one of the payers drops out and that does you know they still have to pay people they still have to pay their rent so one quarter of that in theory one of the worst case scenarios and then they they write that but it might not be correct by the end of the year and so that's what we've done now so I get that but it still seems like a big margin to me if the base is 1.77% and upside limit at 2.7% seems like a pretty healthy margin of error or incredibly catastrophic event happens which I guess could happen but both of them won't let's see I'm interested in some follow-up on some language that was in the board order last year and it was oh it's a great one I'll read it because it's a brief one it says in consultation with the Green Mountain Care Board staff one care must identify a pathway by which potential savings from this model are concerned participating commercial premium rate payers initially focusing on those individuals with qualified health plans coverage through Vermont Health Connect and so I know that this past year has been for some people in the QHP population a good one because of the silver loading but for others it's not so much and I'm still interested in developing having at this point in time as we move forward assuming the best for the ACO that it's going to work and that there will be savings and that some of that might be go back to solve some of the affordability problems that we all know exist so I'm just kind of making that point that that was in last year's order and maybe as part of this process I'd be trying to learn to work with you for some language to update that but I just don't think we should lose sight of people especially the individuals in the QHP plans yeah we haven't lost sight of it but happy to work with you on potential language around that my final one is just a broader question is that in his testimony to us Todd Morris said on the ACO budget when he presented it he said I know that from being in the room that CMMI innovation under CMS was concerned at the most fatal flaw in how we constructed it would be that Medicaid would underpay or even go backwards and that therefore looked like it wasn't providing affordability for Medicare and so I know in the all pair agreement if there are somehow contributions that are directed at offsetting the cost shift that those don't count in the total cost of care calculation but I'm just wondering how would we know if if the concern that Todd raised is actually unfolding over time and I say that when I look at the per member per month increase for Medicaid at 0.51% for 2018 and they're proposed at 0.5% per member per month for 19 and I know how those are determined actually well I don't know precisely how they're dependent on folks like Jackie to tell us that and Sarah but I I don't know where to look to see if the cost shift is getting worse and therefore affecting the ACL in any way. Well so you you're right about being held harmless for growth associated with Medicaid price increases and we're we're working on how to calculate that it takes some time because you got to get the year in the books and figure out what the dollar value of the increase was across all the Medicaid beneficiaries and then so we're working on that for 2018 we're going to be submitting that at some time in 2019 depending on when we can get the data as far as like how it how this is reflect how Medicaid pricing changes are reflected in the rates we're going to try and give you that that number of like what's the overall increase across all the Medicaid eligibility groups and what percentage of that is associated with pricing increases so you should so hopefully it'll be clear to you like what what's price and what are we held harmless for under the agreement yes yep sorry thank you okay I just have a few questions on slide 20 and Sarah I know you went through a lot of numbers on calculations but when we look at the 1.1% and I understand the total cost of care is different than necessarily just the ACO but when we see that the ACO is 3.5% last year and 3.8% this year just on Medicare you know so that would combine to be you know somewhere in between and we look at the measurement of 1.1 this may be offline requests but you know really marrying those two up so so as we look to the future for five years out and be able to understand how we're tracking it's difficult when we're looking you know at a 3.8% this year and then translating that to you know a 1.1% overall and I know that the numbers are you know the population sizes are different for each one but maybe if you can reconcile offline how to correlate the two we're going to get year after year be looking at this compounded growth rate the 1.1 to me was a surprise as being relatively low versus the year over year changes that we know were appropriately granted at 3.5 and then depending what we do for this year you know up to 3.8 yeah sure so and I think I may have misspoke that these numbers are based on the ACO's performance or expected performance so the reason that this might be so so when the benchmark is set just like this year it's based on an incomplete year of claims so we pick that target and that's what we're trending for by the 3.5 but if the base rate ended up being lower or higher that 3.5 isn't necessarily setting in stone how the ACO ACO will grow so we need to complete the hypothetical performance year get the current year in the books before we really know how we're going to perform okay so it's really I think it's just important for everyone to see that we're going to need to track you know the numbers that are improved aren't necessarily translating into what actually is happening and so it's hard to jump to where we're going to net out without that yeah absolutely and another important component is that whereas for the benchmark we're counting kind of the entire shared savings as PMPM for the ACO population for performance I don't think that's appropriate I think we need to spread that through the full Medicare population because they're getting the blueprint payments whether or not they're attributed to the ACO so that's another kind of delta but we'll certainly make sure that we make that as clear as mud no it's as clear as we can and then the next just to talk a little bit more one of the things that surprised me a little bit and I understand when we get the submission from the ACO you know the timing of that and what the actual attribution is changes but when we look at the Medicare risk of 23 million that was submitted and the budget that was submitted from one care had $460 million targeted for Medicare and if that changes to 30 million if that's the new number then that now means there's $600 million that will be attributed through the ACO and I just wanted to make you know just question is that the case because obviously that changes a lot of the budget numbers that we've reviewed and were submitted and when we look at percentages as far as program costs and things like that you know it's pretty impactful if it goes from $460 to $600 I think it's good that we have more attributed there but I think it just shows to the timing and you know so how do we get the new information and you know get the new change on the risk total for Medicare I mean that would be there are going to be moving parts up till the end so I mean it would really be a matter of receiving updated projections from the ACO also the 2018 settlement is going to be a significant alteration so what that should I mean it's a big change to go from $460 to $600 so I would just maybe you know it's revisiting with the ACO you know how we would look at that and to that as well the slide before that that talks about the risk quarters you know if we put on this slide what we had for 2018 right so Medicaid went from I think what was the 3% corridor to the 4% corridor and then Medicare went from the 80 to 100% so we're actually increasing the risk quarters up on Medicaid and Medicare the interesting part about that is when we correlate that to the hospital budget process you know one of the big concerns was the risks that's out there and actually our focus on the downside piece of that and here with the ACO we're actually expanding the risk quarter which puts more potential risks on the hospitals to the extreme you know obviously we hope we get savings right and that opens up from both sides clearly but one of the pressures on a lot of the hospitals were there providing for that downside risk not necessarily forecasting you know the potential savings and just you know this probably is a question back to the ACO but you know how was that received by I know their finance committee approves it but I was surprised so early in the process we're jumping to expand the risk quarters which puts more potential risk as we saw on the you know maximum risk limits out there which are on the backs of the and I you know I understand there's hope for the savings and I hope we get that but a lot of the discussions with the hospitals and how their forecasting has been on the downside reserve and some of them providing for that and this is going to create more and now even more so because we're going up from 23 to 30 million so and I guess the last question I have is really on the commercial and I understand that you know those haven't been negotiated maybe it's not slide 30 sorry on the commercial but once that does get finalized just having the ACO report back to us what the implications are for total dollars if there are changes made one if they are to be consistent with the board order those changes things in for affordability we have things about the HP plans what would that be and I understand there's negotiations still between the ACO and the commercial insurers so that's not set yet but I think in the order that you're putting forward it's that we get what those changes and implications are thanks I have some general comments that I'd like to make observations and responses and comments so that's okay that'd be fine so at this point I'll open it up to public comment again I'll remind everyone to when you're called upon please rise, state your name, what town you're from and direct your comment through the chair who would like to begin good morning still Mike Fisher from Lincoln at Office of Healthcare Advocate I guess I just wanted to say a few words about the process that we're in the middle of and to recognize that the my office has submitted written comments I know that those written comments have developed some stronger responses this year we work harder this year and it sort of leads me to want to stand up and say that the Office of Healthcare Advocate does support the goals of the all-hair model when I'm on my game and doing my job well I take the time to slow down and to look at the cases that come in the door at the Healthcare Advocate's office and it's not unusual that I see one that some version of one that came in yesterday some version of I'm really sick I'm really scared I don't know how I'm going to pay for it so I've canceled all my medical appointments so are we impatient at the Office of Healthcare Advocate? Yeah we're impatient and it's important that people understand sort of the motivators the pressure the reasons why we're impatient if I told you more details about that case half the people half the people in the audience would sigh a relief and say at least it wasn't my part of the system's fault and the other half would groan about challenges that are beyond their control it's a big complex system we get it we get it that is that the task in front of the board is a very complicated one one with some limited limitations of powers and stuff beyond their control and we also get it that to use the metaphor that's so often used it is a big shift to turn and it's going to take time so but sticking with that metaphor for just a minute when when you have a really big shift to turn you put the right amount of pressure on it consistently and so those are my reflections for the day and I want to say again I respect the challenging task in front of the board and I apologize if I sometimes sound like a broken record but I bet you I'll stand up and say something similar in the future thank you is there another comment Susan hi Susan Ernoff friend of Vermont Developmental Disabilities Council and I live in East Montpellier if you could turn to slide 39 it's a slide about administrative expense I mentioned this in my comments but the time that I wrote my comments I didn't have these slides available so I didn't know what the recommendations were weren't going to be and that's how they said you want something your sense of filing anyway last year the board wrote in its order while we believe that the all-pair model holds great promise for controlling health care costs and improving quality of care in Vermont we understand the concern expressed by some that ACOs add another level of complexity and expense to an already complicated and expensive health care payment system board went on to say ACOs should provide a net benefit to the system and we will monitor the expenses to ensure they are less than the total health care savings generated through the all-pair model the board included in its order was clause M I think in its final order one-cares administrative expenses should be less than health care savings generated through the all-pair accountable care organization model so that was from last year's budget order the 2018 budget and we won't know one-cares administrative expenses or the savings generated for 2018 to probably this time 2019 so one of the questions that I raised in the comments was how is that going to be enforceable what's the board going to do a year from now if one-cares exceeded its administrative expenses in 2018 and based on their 2017 experience that seems really pretty likely it could be possible that Michael's right and the one you know their savings in Medicare might be all those millions but really their track record is pretty consistent with Medicare they lose money every year so they had some savings in Medicaid this year 2.4 million apparently in 2017 but that's nowhere near what their administrative expenses were that was 2017 my question in my comments was what are you going to enforce your own order based on 2018 but my question right now here today regarding the 2019 budget is I didn't see a staff recommendation similar to the clause that you've had in the 2019 order and as unenforceable as it might be I think there should be something in the 2019 order similar to what was in the 2018 order that gets at some limit and what I'm sure your goal here that the ACO provides a net benefit and doesn't cost more than it might be saving thank you seeing none I understand that member Holmes would like to bear with me because I've written down my thoughts because I had a lot of them and I tend to like to write on paper my thoughts but first of all a genuine thank you to the staff for all your hard work here reviewing this budget I know because I've been there and I've heard and I've seen spend hundreds and hundreds of hours collectively I think ensuring that we have the necessary information to make these important decisions about how we pay for and deliver healthcare so thank you and I appreciated all of these recommendations that you made today as I review the ACO budget again this week it's been multiple times I'm going to keep going and the first is patience patience has become a lost virtue in our society with one click we can instantaneously see any movie we want we can swipe right and find a date for tonight we can post a picture and within an hour get an instantaneous gratification of 200 likes and that works for some things but not for everything we cannot radically change the healthcare system with one swipe or one click nor should we innovation takes time fundamental system change takes time we need to be patient it's important to remember that we're in year one of a five year model so despite the unrealistic I think expectations of some critics of the all pair model it may take years before we see significant quality and financial results and achieving scale will take time to and it should that does not mean that the all pair model idea is bad or that implementation is not going well what it means as any successful entrepreneur will tell you is that innovation requires a willingness to take risks constant iteration testing and pivoting and above all patients we need to take the long view here the second thing we need to do is stay focused on the vision we had and we signed the all pair model agreement the key question in my mind will be whether this ACO budget helps us get closer to achieving a better healthcare system for all of our monitors about two weeks ago I asked my health economics and policy students to describe the features they think they should mark kids they said literally I have their notes because I asked them to take a picture of it they said an ideal system should ensure access to care it should emphasize population health it should reward high value evidence based care such as preventive care early intervention and disease management it should discourage wasteful over utilization of low value care and the cost of duplication of services it should incentivize the development of innovations that will save lives and save costs it should promote a holistic approach to healthcare must extend beyond medical care to include the social determinants of health then I asked them how they thought the current system of fee for service measures up against those ideals they unanimously agreed that fee for service fails along almost every dimension they also agreed that the ACO all-payer model with its shifting of risk from payer to provider through capitation and its quality accountability has the greatest potential to move us closer to our ideal it incentivizes care coordination and the utilization of the most cost-effective treatments it promotes preventive care early intervention and disease management which both save lives and lowers costs contrast that to fee for service which is not distinguished between good care and bad care under fee for service all care is incentivized so you get lots of utilization even the kind that does absolutely nothing for you or even worse the care that harms you and complex care management well that's not that deliver high value care low cost will be rewarded and adopted in fee for service there's no incentive to develop cost saving innovations because high costs are just passed along to consumers and payers and in an all-payer model providers are held accountable for quality not volume so what a provider does not how much she does really starts to matter so population health should improve at lower costs and as costs come down which many of us including most health care experts agree is bailing along all dimensions but yes the all-payer model requires a complete overhaul of our payment and delivery systems while we monitor the entities we regulate we need to be patient with the ACO and with the providers hospitals and payers who must completely transform their business models operations have to be re-engineered provider practice patterns have to change IT systems have to be developed to allow better flow of information and that is going to take time and needs to be regulated and fortunately because of the green mountain care board's statutory oversight we have one of the most highly regulated healthcare systems in the country but I urge us to regulate patiently as the system transforms itself innovation is risky but fortune favors the bold and I appreciate the healthcare advocate Mike Fisher's comments that you just made and your support of the all-payer model but I still found it particularly disappointing the state's healthcare policies that have been restricted towards a better healthcare system with unsubstantiated and misleading accusations including a claim that the UVM health network is exacerbating Vermont's affordability challenges and undercutting the success of the all-payer model to the contrary the all-payer model would not have been possible but for the leadership of the UVM health network and in fact the communities in the UVM health network the change will never be fast enough or indeed welcome for those patient observers who remain optimistic and are willing to support the hard work that needs to be done to bring necessary reform to an unsustainable system we are already seeing signs of change hospitals that once survived by maximizing tests, treatments and lengths of stay are now working with their provider networks and community partners to find new ways to keep patients healthy and out of the hospital providers directly in schools subsidizing the costs of housing and nutritious food for their most vulnerable patients and they are investing in service lines like mental health cardiac rehab and palliative care that would be revenue losers in a fee for service world the model is showing early signs of success and we should be grateful to the early adopters such as UVM quarter CVMC Northwestern Springfield and Brattleboro and pairs like Diva and the all pair model agreement and the ACO is facilitating that change and ACO I might add that must be the most highly regulated in the country despite me sleeting comments by the healthcare advocate and others about the lack of transparency of one care no other ACO budget could possibly have undergone such careful regulatory and frankly public scrutiny is this one which is good I think we need it but it's happening so as we analyze this ACO budget for the final time ACOs and I have the best interest of the 625,000 Vermonters in mind I will be working to ensure that this budget reflects the responsible use of our scarce healthcare dollars and also that the ACO's programming continues to encourage the type of system change that we envisioned and committed to when we signed the all pair model and I'm certain my colleagues will be doing the same and I would urge all stakeholders in the room particularly those working for state agencies to consider ways in which their organizations are more stable and more effective in the future. I want to comment would you mind if I respond to a couple of comments I promise I will be playing. Okay keeping in mind that it is past the new hour and we're going to be back at 1. Okay Jess brought to mind that struck me that I thought it might make sense to share. One is around scale because I think there's been a lot of criticism both that scale is moving too slow and that change is moving too slow. And those two things to me are in conflict to say both of those things at the same time because I think you can't expect operational change without scale. So I think that that's just something that as we're as we're monitoring the model and looking as looking forward over the years to evaluate that we need to keep in mind because without scale there's no incentive for operations and quite frankly without adoption of the new payment model as we saw with a shared savings program. Shared savings I think was well recognized as not being a sufficient incentive in the provider community to promote operational change. So the other thing that struck me is that there is some literature that shows that medical evidence takes 12 years from when it's a fact to when it is actually incorporated into practice. And so just to support your your call for patience I think that's an atrocious statistic because you would hope for faster dissemination but I think it also belies how hard it is to change operations and change practice patterns. So with that I will conclude. Thank you Kevin. Thank you Robin. Just two seconds. I just though I want to underscore just this point about patience in my in my career here in Vermont I experienced Act 60. Act 60 occurred on pursuant to Supreme Court justice judge a Supreme Court decision on February 15th and by June of that year the legislature had passed Act 60 but it took years for the rollout of that in patience and you can argue pro con Act 60 but it did equalize the distribution of wealth on a per child basis that helped many school districts across the state. Restoring the state's bond bond rating took time and patience on health care. You know in my view this a lot of this started back with the app and then with catamount and then with the waiver in 2005 we move forward with Act 48 and here we are today still trying to solve this problem that hasn't been solved yet. So I would just ask people to step back and and look at anything in the public sector that is significant and transformational. It takes time. It doesn't happen overnight and let's not make you know let's just be sure that we're not making perfection the enemy of the good as we go forward. Thank you Tom. Just reminder we're recessing till one o'clock. We'll be talking about the ship and this afternoon there will not be a vote on the ACL budget that will be on Monday and with that I want to thank the team for again a great presentation. So welcome back everyone. We'll call the meeting back to order and Susan do you have anything to say before I turn it over to Heidi and Dr. Levine? No I actually yes I do. I forgot to mention it's pretty obvious but our general counsel reminded us after my executive director's report earlier today that we won't have a board meeting the meeting the week of Christmas because the 26th for folks who are planning that far ahead. I guess we did announce Monday's meeting but we should also stress that it is Monday not Wednesday next week. That's right and we do have one on Wednesday as well but the ACL budget vote will be on Monday. So with that I'll turn it over to Heidi and Dr. Levine and I'm not sure who's leading the charge over there. It's a joint effort but I'm going to make the introductory comments. Okay. Thanks for inviting us to speak today. I know you've been steeped in budget discussions and budget decisions. I do a lot of reading and you're in the news a lot whether it be editorials. I would like. Editorials, commentaries, opinion pieces. All of them have a common theme. They tell you what your role should be. They tell you what you should be advocating for. They tell you what you should be spending your time doing. How you should strategize. Where the dollars should go. We're going to resist the temptation to do more of that. We're going to come here with one sole goal in mind and that's to engage with you on our state health assessment and more importantly the outgrowth of that which is a state health improvement plan. And we'll make an offer not just for today but for the future. If you'd like our expertise as educators on some of the areas we view as critical to your work and to Vermont's health care landscape please invite us back because we really are steeped in that area that I call the nexus of health, health care, population health, public health and health policy. We know that within health care there's always going to be a tremendous focus on controlling costs and improving quality and improving what's termed the patient experience of care as well as patient access to care. And those are critical components. You'll recognize them as two components of what's fondly termed the triple aim. And it's the third component we want to engage you on more so today because it tends to be the forgotten component and that's population health. And we're going to give it its full due. We now know that the state has really not only dipped its toe in the water but it's really getting more of its leg in the water with regards to the all payer model certainly in terms of covered lives. And that's in a very significant investment. And though we know that delivery system reform and payment system reform are usually front and center and sort of the first two of the three to be addressed. There's of course a substantial population health focus within the all payer model. And there are metrics and outcomes that need to be attended to for us to properly satisfy the mandates of that model. You're probably familiar with the Robert Wood Johnson culture of health multi decade initiative, which is to harness the power of cross sector collaboration to advance health equity and improve health for all. Among other actions, this aims to create healthier, more equitable communities and strengthen the integration of health services and systems. And we of course subscribe to this. In terms of the so called determinants of health, we know that there's only 10 possibly 20% of a person's health determined by clinical care. That leaves of course 80 plus percent related to socioeconomic factors fondly termed the social determinants of health to environmental influences and very importantly to health behaviors. This discussion that we're going to have will quickly show you how the work of our state, not just the health department or the agency of human services, but all sectors of government and innumerable public private enterprises and partnerships and the health department's ability to partner with the health care system can achieve significant progress in the long run, not just the short run and achieve significant social as well as health outcomes and the approach in the kinds of evidence based prevention and investment strategies that we're going to detail will have the potential to truly address the root causes of the health problems that currently adversely impact for monitors and the communities they live in, as well as drive the ever increasing need for services and escalating costs that you are only too familiar with. This presentation fulfills the opportunity to consult with the Greenbound Care Board before the plan is adopted, which I believe is Act 67, 167. We look forward to future conversations as we develop the action plans and support of our state health improvement plan. I'm going to turn the slide-based part of the presentation over to Heidi now, though I tend to interject liberally, but I will resist. I'm going to leave it in the middle so that will be nice and easy. Good afternoon. Thanks for having me back. The last time I was here I was able to share with you some of the preliminary results of our state health assessment and on your desks you will see your own personal hard copy of that assessment. And this was probably about a year in the making. And it was the first step of this process, which was to make sure that we had an accurate sense of what is the health status of our monitors, what are the core health challenges before we figured out what the state health improvement plan ought to be. So this is the basis. I know it's going to be very tempting to be looking at all these charts and graphs, but I'm going to ask you to hold off on that so I can have your attention, and this will just be a nice little goodie to take home. All right. So here's what we're going to do. I'm going to take you through why we are... Oh, we'll see. I could be good. I could not be. Voila. Oh, the colors look different from here. So where I want to start with is just making sure that I ground us all in. Why am I even here? Why have we done this work? How does the state health assessment and improvement plan connect to the work of the Green Mountain Care Board and the authorities that you have? So big picture as Dr. Levine outlined is part of our health system reform and our focus on the triple aim, which is cost quality. And this is focused on our population health improvement goals. And as you know, when we talk about population health improvement, we speak from the doctor for the whole state, and we mean the entire population. It also fits with the ACO and the all payer model in that we are looking to not only change our payment model and delivery system, but we're trying to create some accountability for outcomes, health outcomes. And you all are very familiar with the fact that our existing state health improvement plan had three primary areas and goals and those goals translated into measures, which then translated into the accountability system within the all payer model related to population health. What I'm going to present to you today is sort of the next iteration for you to consider as you think about the work that you're doing under the all payer model and potential expansion in the future. And then as Dr. Levine mentioned, Act 167 was an update in 2018 that made it very clear that this state health improvement plan is the state health plan that sets the health priorities to the state as you consider how you want to work with our health care system in meeting those goals. So graphically, I probably left out a whole lot of things, but trying to make it as simple as possible. How do we get here? So I want to put it in context. So where we started was we looked at the community health needs assessments that each of the hospitals have done. So not this round, but the previous round to see what had they identified as the primary needs in the communities that they serve. We also looked at the data that was collected through the Agency of Human Services Community Profiles work. Each of the district offices of our agency went out and met with community and social and human service providers to see what they were identifying as needs in their communities. So we rolled up the data from each of those efforts to say, here's what we know on the health side, from our health care system, here's what we know from our social service system. And then we added, we brought that data in as we looked at our state health assessment. And many of you know that we have a very robust data center within the health department's inability to analyze data that we that which we technically own or govern and that which our counterparts do. And we look at trends over time, place and subpopulation on a regular basis through our surveillance system. But then with the state health assessment, we want to go and we dug a little deeper and we said, not only do we know that, but if we're going to take this equity lens that Dr. Levine mentioned, we want to dig a little deeper and see what do we know about particular populations that perhaps we have some inkling might be being left behind or experiencing greater health impacts. So that's what the state health assessment was. What do we know about the health of our monitors? The state health plan that we're going to talk about is, what are we going to do about it, right? But it really at this point, the plan is really a set of high level goals and strategies. The work plan is what will come next. And we're hoping that the work that we have done, you will be able to use in the work that you're doing with the all pair model, both to look at your goals and priorities. But the data that we've collected, the engagement that we have done with about 180 different entities in the state, a lot of them statewide or community wide partners to look at needs and data is something you can draw on when you are looking at the multiple decisions you need to make in regulating and approving our how our health care system moves forward in the future. So reiterating so the state health assessment is what do we know about the health of our monitors? The state health improvement plan is intended to answer what are the priorities? What and what are we going to do about the priorities? And I just want to reiterate what Dr. Levine said and that the state health improvement plan, while it is shepherded by the state health department, it's within our mandate to carry it out. It is actually intended to be a plan for our state partners, public and private. And then you'll see when you see the scope that it is designed with that in mind, it is well beyond the capacities, authorities and and really the place for the health department to be in the lead. But we offer this as a guidepost to our multiple partners in and outside of government. I'm going to pause just for a second to make sure that you understand that what's reflected in the state health assessment and the improvement plan does not necessarily take the lens of the majority of Vermonters like what are the majority of Vermonters experiencing? Because we really wanted to look at inequities. And that is because we know we have so much in play already to meet those who are in highest need where we're seeing that the greatest health outcomes, you know the highest disease outcomes related to chronic disease or suicide, you're already tracking those, right? But what we didn't have data for want to make sure we were looking at instead of looking at everyone, what if we started with the people first and said, we know that there are certain populations that historically have had disparate health outcomes based on inequities. And that means that they have the way that our society is structured, the way that decisions are made, the way that power and money flow, the way that history has presented itself. We now know that there are certain communities, not just geographic communities, but certain populations that are experiencing differential health outcomes based on race, class, gender and disability. That's been proven in the literature again and again in other states. And there's frankly no reason to believe that we're any different in Vermont. But we did choose to look at it and make sure that our patterns weren't any different. So the state health assessment really focuses on that. And therefore the state health improvement plan will have a mix of those things that are for the population in general, and those that are specifically targeted to these specific populations. This is a long way of saying it took us two years instead of one year to get to our state health improvement plan. And the reason being, we really wanted this to be a community engagement process as much as a data dive and planning process. And the reason that the community engagement process is so important is twofold. One, there's not we can't possibly know everything from where we sit in government, or in our agencies or on the board, we need others perspectives to understand what's really going on in community, and what the meaning is of the data we're seeing. Because we can describe what's happening, but not why figuring out the why we need community partners to help us and others, right? And then the second reason to make sure we had such a robust partnership in doing this is that we're going to have five health priorities and close to 20 strategies that are going to require the participation and the leadership of many of those partners because many of the things as Dr. Levine said many of the solutions lie outside the health care system, right? Because many the what the health care system can do is address 10 to 20% of health outcomes and the rest needs to be by changing the conditions of people's lives by working on health behaviors and that takes more than our health care system alone can do. So having those partners engage with us from the beginning was extremely important. So this is the very quick list as the highlight summary from the state health assessment. Basically when we rolled up all our data from the community health needs assessments from the hospitals what we saw in communities through our social service agencies, and then the data dive that we did. And we had all those partners look collectively with us about what are the do going through a ranking system to find some priorities based on opportunities for prevention opportunities for improvement impact on disparate populations. These are the ones on the left hand side that popped up. There was consistency both with our internal so called data and program experts, as well as our community partners around these five priority areas. So child development, chronic disease, mental health, oral health, and substance use disorder. Not a surprise. Three of these are ones that are already part of our all payer model. Health outcomes don't change at a population level do not change that quickly over time. So there's some continuity between what exists now in the current state health improvement plan and the all payer model and what will be moving forward. The addition really is childhood development in oral health. And oral health I know is somewhat beyond the purview right now of the all payer model because of the total cost of care. But I would say that in in conversation with our community partners, they ranked oral health the highest priority need. That is where they we are seeing the most significant gaps in meeting the needs of our communities is addressing oral health needs. So I just want you to take note of that. The social conditions that are on the right side and you'll notice I moved from determinants of health to social conditions. And I'm waging a personal campaign to get where the reward determinant because it sounds deterministic, right? It makes it sound like you can't change it and the reality is you can. It's a condition we can change those conditions. So the social conditions are housing, transportation, food, income and economic security. And what's not on this list, but will be on the list in the plan as we move forward is discrimination. So because in conversation through our outreach, that is the piece that related to the inequities that there is there are many Vermonters who are seeing patterns of whether it's institutional discrimination or individuals discrimination that that are impacting their physical and mental health and well being. And so that is a condition that I think will be added in that we can change. I'm going to skip this one because it's not useful to this conversation. The selecting of strategies. So you know, this was just the process that we did. Again, it's what do we know about health? It's the data from the assessment. And then we charged ourselves that looking at the literature. We said because the two mantras in public health are data driven and evidence based. So we did that work. We looked at the evidence to look at the literature. What do we know the proven strategies? But then we also asked our community partners, what are some promising things that are happening in Vermont right now? Where are we getting some traction? And where are we seeing some positive outcomes? Because there's a lot where, frankly, we are on the cutting edge. And we there's a lot of innovation that's happening in Vermont that would not be captured through the evidence based literature. And we felt that was really important to include. So we looked at both of those. And we we brought to our community partners. As I said, I think 54 strategies that met both of those criteria. So it was evidence based, promising practice in Vermont. It addressed inequities and shows major opportunities for prevention and upstream action that would ultimately both improve health outcomes and also reduce health care costs. So we brought 54 to our advisory committee and asked them, where do you see there's readiness for action? There are a lot of different criteria we could have used for priority setting. We particularly chose readiness for action. Again, because we know that this plan is not one for government only, right? This plan has to be embraced and moved with our partners outside of government and in community. So readiness tells us that if it's what can move, because you can have the best evidence based strategy. And if no one's behind it, it's a non starter. So that was our primary criteria after we used our other ones to figure out readiness. I don't imagine you're going to be able to read this. Good luck on the with the handout, but I'll try and walk you through it. And this is the one page summary we're working from now. The language is terrible. Let me just acknowledge that there'll be a lot of language changes. And there's a lot of as our secretary of human services said, bureaucratic gobbledygook listed here that the average person is not going to understand. So by the time it is translated into a state health improvement plan, ideally, this language will be cleaned up and recognizable. But we didn't want to go through that finalization process until we had a chance to check in with our partners to make sure these are the things that are moving forward. And then our oh, so talented communication staff who put together this fabulous document, the state health assessment will help us in creating narrative that is more transparent and ideally motivating to folks outside our little world. So the vision is all people in Vermont have a fair and just opportunity for healthy for health and living in healthy communities, right? So we wanted to make that connection between individual health and the health of the communities. This was the vision that was created by the steering committee and the advisory committee and I jumped over the fact that our steering committee includes our secretary of the agency of human services, of course, Dr. Levine. We also have Martha Maxim, who's the deputy from the the agency, Todd Moore, the director of One Care Vermont. Sarah Squirrel, who's now to be the former director of Building Bright Futures and our new commissioner for mental health. And then Mercedes Avila, who has been just an outstanding advocate on health equity and our health care system. So those have been our steering committee members and this has been vetted through them and supported. So the outcomes you'll see are a little bit different than those five priority areas because what we know is the interrelationship between mental health substance use chronic disease early childhood. If you keep moving back to the why we see in these health outcomes, the drivers are much the same and that's how we wanted to be able to organize our strategies because there will be many strategies that ideally are going to hit those multiple health outcomes rather than going one health outcome by the next. We think if we are creative, we can have a much more powerful outcome. So the outcomes are that Vermonters have access to the resources needed for healthy living and healthy aging that all children achieve optimal child development. Vermonters have lifelong opportunities for oral health and that Vermonters demonstrate resiliency and mental wellness. So that's where we're aiming for the overall themes of the strategies that we're going to take are in these three buckets, right with the fourth one underneath being the foundational piece. And I'm going to speak to that just very quickly. So the first category is about investing in community infrastructure. So as Dr Levine said, where we live, work and play, the ways in which our communities are designed and the policies in communities make a tremendous difference in our access to healthy behaviors. You've probably heard our mantra from the health department, which is making the healthy choice the easy choice. And that's recognizing that in order to have choice and make good choices, you have to have good options. So you need to have access to healthy food. You need to have access to transportation. You need to have healthy, healthy building codes, et cetera. And so that's what that sort of that investing in community infrastructure is all about. And the strategies that you see listed under there are all evidence based strategies, a number of which have been designated by the Centers for Disease Control as part of their health impact in five years, their high five priority strategies, where they are able to show through their evidence that investing in these has a five year turnaround, both on positive health outcomes and return on investment over the lifetime of either the program or the person. So the ROI is not in five years, but the health impact is in five years. So you'll recognize some of these. Your staff helped work with us on some of them. So using payment reforms and regulatory levers to invest in housing, food and transportation. We've seen some great examples of that already in Vermont. I know you've you've looked at some of the great housing work that's been supported through our health care system, expanding subsidies, loans and grants for weatherization. This is one of those high five. There is proven literature that if you improve housing conditions, particularly through weatherization, you have a positive health outcome on multiple levels. But of course, the closest is asthma, one of our primary costly health outcomes and chronic diseases, creating transportation to increase connectivity and reduce isolation, expanding community water fluoridation and promoting healthy community design. The three middle ones, so are all part of the high five. And additionally, the strategies so that in the middle, that second frame is building individual and community resilience, connection, belonging. You have heard a lot about this through the average child events. You've heard presentations about that, about building flourishing communities. That's sort of this is that centerpiece where if we have early investments in children and families, they will have the skills, the resources to manage their own health to as prevention. And so within here we have expanding home visiting services, promoting, strengthening families, implementing school health and wellness, expanding youth mentors, peer programs and supports and creating community based recovery. So a lot of what's here is that intersection between early childhood substance use and mental health, right? That's what's really being addressed in this bucket. Chronic diseases, primarily the first one. The middle is a lot about that sort of the more mental health substance use early childhood. And then it's third one is one that we know you all care about intensely and that is about increasing access to care and services. And as we know, you'll see there are a number of different strategies. One is about integrating primary care and health, mental health, oral health and substance use, right? We threw in oral health, not usually part of the scheme, but we have some really innovative pilots here in Vermont right now where that's happening to great success. Investing in telehealth and telemedicine modalities, including oral health. And then you've heard a lot, I know about S-Benz, the screening brief intervention and navigation to services for social determinants and healthy behaviors for all children and all families. The goal here is that we'd have some common criteria and screening tools that could be used in multiple settings and shared across so that we can start digging away at those things that we know are contributing to poorer health outcomes. As I said, the foundational piece here is adopting organizational institutional practices for increasing equity. I would have to say this has been the most challenging part of this process for us as a department in leading this because we thought we were so great on health equity and we were just going to be able to bring to everyone the great things we're doing and we are finding just how hard it is. And so we've put it here and we know this might be one of the hardest things for us collectively to do and yet we know that if we do it, it actually will have the greatest change. So we could frankly skip over the middle strategies. If we were to really look at our policies and practices that unknowingly reinforce in equity, we would actually have greater health outcomes, more positive health outcomes. So let me just show you the frameworks we're going to use for these strategies. Give you an example like so what does this all mean? So there are two different ways we're going to look at the strategies and the health outcomes. This is the traditional way that we in public health look at things. You might be familiar with our social ecological model, which is a prevention model. And what this basically says that if you want to change a health outcome, we need to be working at multiple levels, the individual relationships, organizations, communities and policies that you can't focus just one place, right? That you need simultaneous action in all of these ways. And here we're showing you some of an example using substance use prevention model, right? And so you can read that at each layer there are different programs that are targeted to the different different circle as it were, right? This is how we traditionally think about things in public health. I'm not going to bother reading it. It's a very, very useful tool. One of the things you will hear us say is, and some of you might be familiar with the Thomas Friedman pyramid, a health impact pyramid. And basically they put this into a pyramid this way, but it's opposite, recognizing that working at the individual level actually is has the lowest return on investment, right? Because you're working one to one to one. So if we're thinking about making broad scale societal changes and really changing things over time, the more that we can invest our time and energy in policies and systems and communities, the bigger bang we're going to have for a buck, because we're setting in place the conditions for health. And we're not reliant on individual behavior, which as you know is very complex, right? So changing behavior is much harder than early adoption, you know, adopting behaviors early based on circumstance. The other framework we're going to use, which I think might be more useful for the work that you do is this three bucket strategy. And some of you may be familiar with it. It was developed by a former director over at the Centers for Disease Control, who now works for the trust for America's health. Dr. John Auerbach in collaboration with his friends over at the CMS. And what they were trying to figure out is, when we talk about where's that intersection between public health and health care, and we're talking about the range of prevention, how do we work together? They came up with this schematic. And it's really looking at how do we integrate prevention into the different domains of action with the health care system. And so the health care system, traditional clinical public health, excuse me, clinical prevention is using the medical evidence based strategies in the clinical setting or strictly in the health care delivery system. In the middle is sort of that innovative place where you bring together the clinical and the community. So for example, our blueprint for health and the community health teams has moved into this middle bucket. They were there doing a lot of integration between what's needed for the individual in the medical care setting with what's needed for them in their social and human services. That's an example of what would be in that second bucket. And then the third is where we've traditionally lived in public health, which is these interventions that are community wide that help the whole population. This is the framework that we've been working with one care. And with our partners at blueprint, where we have actually used this for the existing goals for the state health improvement plan. And we said, okay, so if the goal, for example, is reducing chronic disease, how are we going to measure that? And how are we going to know for getting where we need to go? And what needs to happen in the health care system? What needs to happen in that clinical community setting? And what needs to happen community wide? And we created what's called prevention change packages that shows that line. So you could see we actually took the measures, the current measures for the ACO and we matched them using this system so we could show how we collaborate and how there's there's actions needed in each of these domains or each of these buckets in order to get to improve health outcomes. And our intent is to do the same thing with the new goals for the state health improvement plan. So I'm going to give you an example, right? You need examples from the previous slide or you're on board with the three buckets. So here's one. I'm actually just in case. So the infrastructure to create healthy communities that remember that was the left hand side of that crazy piece is so the idea is what would we do to create incentives and flexibility and health system financing to fund local upstream efforts and social determinants of health. The health care system could be working in buckets two and three in new ways. So one would be to build or purchase housing for the homeless to improve diabetes and asthma management and reduce readmissions into the hospital. We have examples where that's already happening. It's saying this is a best practice that we would like to amplify. If you put an equity perspective on it, you would be saying, well, you would be prioritizing funding for communities identified in the assessment, meaning our LGBTQ population, populations of color, low SES or disability, because we know that folks in those categories actually have a harder time getting housing and maintaining their health without housing. An example of building resilience in bucket one would be screening all families for the social determinants. And I would say and for health behaviors. We've added that in medical and early care and in educational systems and then connecting them to services. It's the suspense. And bucket two would be expanding the home visiting services for pregnant women and families and equity. I don't know if anyone's familiar with this, the class standards. But the idea is that we class standards are the cultural linguistic appropriate services in health care. There was a movement of foot probably about 10 or so years ago to try and they were pretty broad. But basically it's recognizing that culturally appropriate linguistically appropriate care is essential if we want our patients and our population to be able to understand their health and take agency over it. And so the recommendation would be to assure that we are including bias training and reducing stigmatization in our health care system. And the last example is the access to person centered care. And there's opportunities for exploring innovative payments and delivery models. That's what you're doing. Examples would be is there a way to think about integrating oral health and health care settings? How do we do that if we know that that is the number one concern of people in our community right now. The second would be in this oral health also is being allowed to have oral health services provided in different settings by different providers. So we know that there are some barriers right now in terms of allowable reimbursement rates in our health care system around oral health services and who's allowed to be a provider and in what setting we'd like to see that expanded. And then again would be adopting class standards. So those are the big strategies. I'm going to take you through our plan for finalizing the plan and then I'm happy to have us both answer questions. So remember we got to this point which is where is their readiness for actions. Those strategies I gave you we have multiple partners who are ready to work with us. But what we haven't done is we haven't engaged with the communities of people who are actually living with whatever health outcome or disparity or inequity. And in order to do this right we have to go that next level because the more we say for instead of with whether it's with our communities or whether it's with our patients it doesn't work. Right. People have to be engaged in the decisions and in the in the work together. So that's our next step. Additionally we need to build the accountability and monitoring system. So we will have outcomes indicators and strategies. So we're working on a dashboard. Just like we have dashboards for our current state health improvement plan and outcomes we will have a public facing dashboard that has population health outcomes meaning indicators that we're going to track with target goals of either five or 10 percent improvement over the next five years. And we're going to identify lead agencies or partners who are will so-called own those measures and the work that goes there because for example there'll be mental health measures that the health department went on but our partners over in the Department of Mental Health went on. There may be some things that one care or the health care system one. So we're working on that. And then we're going to work on the developing a shared agenda. So those and that means really spending some time with the populations if we continue our equity work it's really building better relationships with some of the folks we've begun to develop really nice partnerships for example with with pride the pride center and the LGBTQ community. And we have an existing advisory committee with multiple entities on disabilities. We don't have such a thing for working with our populations of color. And in that is our native populations and our which is something that if we look at our data we are seeing really much higher stress and poorer outcomes. And so we have a responsibility to as I said dig a little deeper with these populations and the work plans that will include components of having them drive some of the strategy implementation. So I think that's where I'm going to close. It was a lot. You will see in if and when you are curious there are details of every thing that I talked about and just so that you know there you'll see there's some really fun little colors there when you get into the details of the strategy. So here's one like for example about integrated care which you probably care you know you will see our goal was to identify strategies that if we target it at the right level would have multiple positive health outcomes. Right. And so what you'll see in here are the the categories that they would hit. So this first one the integrated care would hit chronic disease childhood development oral health mental health and substance use versus expanding for telehealth for oral health is only marked as oral health. Again it's a way of us further prioritizing to say if we if we are limited in our ability and we need to roll things out over time let's focus on the ones that we know will have the greatest impact on the most health outcomes as opposed to going individual health outcome by health outcome. So hopefully that will make sense as you get to look at it a little more closely. Dr. Levine what else would you like to add? Two quick comments. First comment is on the very busy slide. I will go back to the very busy slide. I'm less harsh on our group than Heidi is. And I would say perhaps one third of these one could have characterized as perhaps public health gobbledygook. But two thirds are pretty explicit. Expand community water fluoridation. Expand home visiting services. I think I understand it's pretty well. And I think the reader even not steeped in the areas we are can understand those. So we do have a little work to do on them, especially the ones on the right. The more wordy ones. But I think we're close. Second thing is I'm always fond of reminding the group using that colloquial expression. Rising tide floats all boats if that's truly what it is. Even though we're trying to really inform you about our equity lens and pay attention to it. And it is our mantra. And in fact, it's not only Vermont's mantra, but it is catching on across the country in terms of states' attention to their health assessments and improvement plans. The fact is there's nothing in here that won't benefit all Vermonters. And that it needs to be recognized that we're not necessarily looking so specifically at a population who requires us to. We want to pay attention to that, but a byproduct is going to be all Vermonters are going to benefit from the same intervention, the same strategies. Please ask questions. Great. We'll open up to questions. You want to start, Robin? Sure. Thank you. This is very interesting and it's good to get an update on where you are in terms of the state health improvement plan. And I guess I wanted to start by saying thank you to you, Dr. Levine and your staff for working together with our staff on how we can intersect the work that you're doing in this area with our work on the health resource allocation plan because the two need to be interrelated in a very deep and meaningful way. So I wanted to thank you for that. In terms of questions, I wanted to, I was noticing, and I'm sorry to jump right into the weeds, but I was noticing in the appendix that when you, specific to the use of payment reforms and regulatory lovers, that you've indicated a priority of social determinants of health. And I wonder if you could just speak to that a little bit and maybe how that may also have some interrelationship with substance abuse or mental health in particular. All right. It's slide 20. There. Oh, I was there. This one. Yes. The third bullet. If you could just speak a little bit more to why, why you chose social determinants alone versus some of the other priorities and you don't have to answer it now. Anyway, I was just curious about that. We can. I was just referring to it. OK, part of it because I think that there are opportunities in the work that you are all overseeing to to recognize that the the opportunities that are presented when our health care system does invest in the determinants. And so when I mean the terms here, remember, where the housing, food, transportation and economics stability, right? So it's really the first three where you where the health system might be investing in. And we've seen some examples where we have seen our health care providers, actors step in and provide housing or provide transportation. But there's a question of whether that's a legitimate spend, if I understand. And so really looking at sometimes we create unintentional consequences when we tighten some rules and regulations and are looking very closely at budget allocations and spending that may then preclude us or not from investing in the things that we know longer term would make a big difference in reducing health care costs. So it's sort of looking at taking an open eye to looking at that. It also came in in a very particular way in that from less from a longer term social perspective and more from I have an individual client who is suffering and needs help. Transportation is a tremendously difficult issue for people who can't get to the care that they need, right? So it's whether they can't get to the care and services they need or they can't get to an affordable grocery store, right? And so for each of these there's an opportunity to look at how does it impact the individual and then how does it impact the community? And so the hope is that as we move forward and we are looking at updating and innovating that we will be looking at both of those levels and because we would contend that if we don't invest in these foundational determinants, we'll continue to have a stream of very sick, very costly people coming through our health care system and it will be impossible to get ahead of the health care costs and controlling those costs. And that in fact it's by investing in some of these things we're able to get there. Just to expand one thing because we kind of think of ourselves in Vermont in this very insular way and we've got this really special all pair model deal. And if we think a little bit more broadly to all the other states, Alex Azar from HHS, you know, has just come out with commentaries, no firm strategies or policies yet but commentaries to the effect that it's probably cost effective for Medicaid to fund housing. It's probably cost effective for Medicaid to expand what it does in transportation, etc, etc, etc, which is really revolutionary talk for those that entitlement program hasn't spread it to Medicare but just Medicaid at this point in time, I imagine because the states have to put a fair portion of the bill. But at the same time, you don't hear that kind of talk every year from Medicaid. And it makes us almost believe we're on the cusp of something revolutionary where the recognition is that Medicaid can continue to pay the health care bills. But really is that what we want to be doing? Maybe we need lots of those health care bills and we could achieve that goal by investing in the way described. Thank you. And then my one other question was, and I know this is not really in the scope of the state health assessment, but I was curious if you had thoughts or in your work, both on the assessment and the plan in areas that you thought we should be deprioritizing or investments that you think should be shrinking because of course, there's in order to find funding for one area, sometimes there is a finite amount of money. So, you know, I'm asking you the hard question that the HRAP asks us. Yeah, so the last state health improvement plan had chronic disease because it takes years and had a combination of substance use and mental health. And then the third category was immunization. We don't necessarily believe we need to defund immunization, but we kind of thought we did a good job on that. There's a lot that's happened, and much of it happened through the policy lever, which is very, very important to recognize. So there needs to be, if you will, less system investment in that arena than what we're already doing now, and we can do other things at other levels of the Vermont Preventive Framework Model to improve on our immunization rates in specific areas like HPV compared to the more basic immunizations. So that's one answer. Yeah, it is really hard. We, you know, all I can say is that getting to this point, we started out when we were doing the state health assessment. You saw that we ended up with five priorities. We started with 165 different priorities to get down to five. So in a sense, by going through that process, we we said everything's important, but only a few things can be priorities. And so I think that's what I would say, you know, really looking at the data, having very clear criteria. Those for us were about human impact, social impact, economic impact, opportunity for prevention and evidence of something's working. You know, so I think I think that's what we have done. And what we haven't said is we're not going to do things, but they are going to be lesser priority, which was really hard for some of our folks to accept. Very, very hard. But and again, we kept saying the way we're going to do these priorities, it was recognized that if we push one lever, it's going to have multiple positive outcomes. And so really just saying that's what we need to do. Unless we have such an intense health need that it needs a singular strategy. Thank you. The other questions. Maureen. Actually, it's somewhat of a follow up to Robin, but I guess I was going to ask you specifically a little more detail about how you think the green man care board can help reduce the disparities and improve equity within some populations. So in our, you know, open terms regulation or hospital government regulation. It's an excellent question. What I don't, let's say, do I have here the greater detail about, I think I do. Let's see. If I can give a. All right. These are really broad strategies for that we're thinking are part of the assessment and part of the planning so that we are not unintentionally reinforcing inequities, right, which is the best place to start, right, because it's not because somebody is purposely being discriminatory. It's because we have systems that have been in place historically. So I think it is this question about bias and racism within our structures and policies, because you have the tools, right? You're asking about hospital budgeting, you're looking at the a trap. So the first is you could use some of what we've been doing in this whole thing was recognizing that if we were going to address equity, we had to look at what data were you looking at? Who's part of the looking at the data and who's part of the decision making, but really being really clear about that and then charging people not only to show the data, but the why, right? So I know, for example, when you are looking at the hospital budgeting, you're looking across so much data that your hospitals are providing to you. I wonder if there's an opportunity to ask for the why, whether hospitals are being asked or health systems being asked to what are the driving forces and are you looking at those driving forces? And some of those driving forces are the equity forces. So that's a very broad answer. But I think there's there's a piece there. I can also share with you after the fact some of the pieces that we're starting to develop internally at the health department in terms of language we're going to put in our contracts to make sure that we're looking at the money that goes out of the department. Is it specifically looking at populations that have been impacted by inequities? Are they engaging people in particular ways? And then also looking at when we look for funding, are we asking for funding using a certain set of language? So we it's always kind of a and the easiest is always to say who's affected? And when you ask who's affected? And who's part of the decision, you kind of get at it. Those are the two routes, right? And so the who's affected if you ask a little deeper about the actual people you get there. And in my opening comments, we said we weren't going to tell you how to do what you do. So when we look at what the UVM Medical Center did, you know, a year ago when they had tremendous earnings and dedicated a portion of that to housing. And I think have shown pretty convincingly that that was a wise investment in terms of, you know, return to emergency department visits, return to hospitalizations in the population that benefited from that. Other populations are other medical centers, hospitals are thinking about activities like RISE Vermont, but not exclusively RISE Vermont and trying to do something in primary prevention with a portion of their revenues. And I guess I would say, this is what it's all about. If you really want to go as far upstream as possible, both of those examples, I know those are really challenging in environments that have so many cost constraints, but these hospitals every three years have to do their community health needs assessment. They have to show that they're actually paying attention to them. And that does require some level of investment. And so in your regulatory function, recognizing that fact is going to be very useful because most of the time, the things they want to invest in will probably benefit one of these populations that suffers from inequity, much more than the general population at large. I just a question on when you talked about selecting your strategies, and that you had 54 that were brought to the committee, and you were prioritizing those that were the readiness for action. And I just wonder, are the ones that they're ready for action? Are those the ones that, you know, that should be the ones we're going after? I mean, I understand there's resource issues and you want to look at, you know, these are the ones where we're ready. But does that align with where you think we need to prioritize if we if readiness wasn't the fact? Yeah. Yeah. So you'll see that was the first cut. And then the second cut, if you see how the the details roll up. Oh, no, I don't actually have the rankings for you. Sorry. So what we did is we looked at the advisory committee committee did by readiness. And then we did two more overlays. One was to look at was there anything that was in the health impact in five years that hadn't been included that we know ought to be included. And we put those in. So fluoridation wasn't readiness. And we said, we can't possibly have a state health improvement plan that includes oral health and not include fluoridation. So there were examples like that where we added those back in because we know that we can have a major impact if we choose to do it. And then there were a couple that we added back in because they were the ones where there was that lovely color coding that showed that it like the same strategy with impact five different outcomes. We added those back in because that again was we know that's where we need to be in addition to where our community partners are ready to go. Great. Thanks. The other questions. Tom. So I'm curious as to even within the agency, you know, your level of kind of scrubbing with this as a background. And I'm thinking specifically of the state's benchmark plan for the QHP population where as I'm just beginning to get a feel for this, but where CMS is kind of saying at least that they're going to change some of the regulations to give states more flexibility in terms of defining the essential benefits in the state plan. For example, in allowing the state to swab out one benefit on an actuarial basis and put another one in that the state feels is a better investment. So I'm wondering if and I also kind of think just briefly at the federal level on the income tax form, your federal income tax, you can deduct as long as the doctor prescribes a fitness center in terms of a diagnosis of obesity or, you know, for weight loss. So, you know, the federal government will allow you to deduct that as long as the doctor prescribes it. That might be something that could we could look at in the state of Vermont in terms of our benchmark plan as a way to get a chronic disease. So I'm wondering if whether or not you're taking your approach and looking internal to make sure that the agency's efforts are fully aligned with where you think we should go. So we just came from a presentation last week to the agency to introduce everyone to what's going on here, even though many had been partnering with us already and helping develop components of this plan. So just to diffuse the knowledge across the entire agency of human services, I will say that what you've described about the essential benefits, I don't believe has even come close to operationalization at the level of the agency right now. It's not a topic that's coming up a lot because I'm not sure how how much certainty there is on the federal level in terms of the direction about that. But I don't think it would provide tremendous challenge to what we've outlined here because I don't think I think most of these fit pretty well in some of the prevention kind of benefits that are ordained. And I can't imagine those disappearing. So I'm hedging a little, but it's because it's not really been a direction that we've gone into in great detail. I mean, you know, I just I look at our benchmark plan and prevention counseling is is free. It's pre-deduction, pre-co-pay. But once you get there and your primary care physician says, well, you need to lose some weight, there's no help for that. And that just doesn't make sense to me. And so, you know, and I agree with you that I don't think CMS has kind of settled in on these reforms that they're publishing now. I mean, these are in their published rules and and Robin had some good discussions about it. She thinks it's just a possibly a situation where you still have to go to CMS on each individual change to get approval. But the door is open to crack. And I'm thinking in terms of obesity and the chronic the disease rather than just having your primary care physician tell you you've got a problem, you know, that they can prescribe something for you that your benefit plan will cover. That would be tremendous. And in fact, we you may know we've been successful over the last couple of years in being able to change the way that we're able to access on the Medicaid side for tobacco cessation, right? They used to be don't smoke. And now we can actually get our physicians and our primary care can actually code and bill for referral to services and nicotine patches and all of that. And we do need that same level of ability on obesity prevention. We we've had some conversation with our representatives in Congress and the Senate who have been really we have some foodies who are just fabulous as you know through the Farm to Plate Initiative who are really excited about the idea as food as medicine and some of the experiments that are happening in other places and how that is both great for hunger reduction but also for obesity reduction and is there a way for us to be looking at some systemic reforms around food as medicine as well. So we will be exactly exactly. Yeah. And so and how do we how do we amplify that and make it so that people know that it's possible and then want to have some uptake on it? So I think that could be an example of a strategy that fits very nicely within the state health improvement plan and that we have been in discussion with folks through the Farm to Plate Initiative who would like to have that sort of be their contribution towards our state health improvement plan. Similar to how we've had some conversations with our agency of transportation and their network of regional planners who are very interested in this question of how do we make the transportation piece part of the plan? So I think we're going to have some really nice partners and as Dr. Levine said we welcome partnership with you too because where we live we're not necessarily looking at the CMS regulations and the essential benefits and what those levers are and so we welcome a partnership with you and your staff to look at where we can think more creatively moving forward. That would be very helpful. Really cool national example right now though is in Pennsylvania and it's being published Geisinger Medical Center is providing groceries for all of their diabetic patients that are within their own health plan and showing reductions in hemoglobin A1C levels just by being the purchaser for their groceries and kind of ordaining what is a healthy grocery purchase versus what is not. So I fully expect that that Jess was going to jump in and mention tobacco and talk about churros. It didn't happen. We do a lot of talking about churros. That's a really great example Robin where some of our folks have said haven't we been successful with tobacco? Isn't it time to back off a little bit on our investments in our strategies and lo and behold here comes Jewel. And Jess, it's my little obsession that I have a head of middle school now. Oh gosh, yeah. I'm willing to be a partner in helping. Fabulous. Just watch the next legislative session. So I don't see any more questions from the floor so I'm going to open it up to the public. And if you could address any comments or questions through the board and start by standing up and saying your name and the town that you're from. I'm going to have to apologize. I have to be at the Marijuana Commission meeting because it's the final presentation of my committee there. OK. I'm sure Heidi can I will stay. Heidi is more than. Thank you. Thank you, Dr. Levine. Very informative. Dale. Yep. OK. I'm curious. I come from a multiracial family. Let's see. My mom would be Irish. I would be white. Or is it white? Very easily red. Yeah. Yeah. Exactly. I am getting to a point that kind of it frustrates me when I see it in the deaf. You see white. White can be many things. It can be Irish. It can be many things. My granddaughter is Native American. I've heard her called Spanish. I've heard her called Native American. She lives in California. Out there, you speak Native American and they think you're speaking Spanish. So I get kind of confused because I've even heard her say this because she even texts this to me and said, everybody tells me what I am but nobody asks me. So I'm just trying to explain why I'm asking the question. What is color? So Heidi, what is the definition of personal color? So yeah. So we use the census data to pull from as our base and so it's however that has been defined and self-reported. And Dale, I think the point that you're hitting on is very relevant to the conversations we're having today because the whole notion of race is pretty much a social construct. Right? It really is. It's just how we have decided at various times throughout history to define people. Right? But the unfortunate thing is when we define people in certain categories, we are also pushing them into categories where there are some who have and some who have not. Some who are advantaged and others who are not. And that changes over time. But what we know historically in the United States is that whoever decided what was a person of color, there has been some systematic discrimination and practices over time. And so we're just pointing out that that's what it's been. We are not trying to create a movement that changes the definition, but we're saying we're working with what has been defined currently by our census department. Certainly, go ahead, Dale. Thanks, Dale. If you'll excuse me. Dale, I have an extra copy here. I want you to take one home with you. OK, because you can see a little bit more detail about how we use the data categories and how we talk about it. And I think you're hitting on some common themes that we heard through the folks who are part of our advisory committee. And our data reflects that our populations that are so-called non-white populations and then we break it down in different ways that we see differences among those populations and certainly our native populations and our bi-racial, self-reported bi-racial populations are the ones who are demonstrating the highest levels of depression, the lowest levels of mental wellness and physical wellness as well in many categories. So I think you'll be interested. OK, other members of the public? Yes, Ken? You would have to be a dream. I'm here for all this work here. And one of the dirty little secrets is that, you know, in the 70s and the 80s, in most departments, the indicators and research, but at least there are a lot of, also to say, the occasions you might want to, has some dollar assessment for the proposals that you are the notions you come up with that you must ultimately ask it to be a challenge to lay over. And I assume one of the populations that are looking at this are people who are electric fissures, electric fissures. Having said that, we welcome on, I guess, I'm hoping there will be such a focus on existing power structure of so-called experts. It doesn't mean that you're not experts. It would be really interesting to take this project as a consumer patient focus, which would ask a question from the same kind of questions, but a little more definitively to consume the sensations. And I think that a lot of information could be gathered. It was part of what I think projects like this do is it creates some baseline information, which is usually missing from all the work that we do. No one knows two years ago what certain costs were, so it's hard to project which direction we're going in. So just kind of the questions that I would pose demographically somehow and there are ways of doing this and it sounds like there is a commitment for certain populations to leave down to the people. But just to trust the board because part of what I think we're doing is we're moving from one system, a V-day system, to the ACO model of a one-care system. If you don't have some baseline data about consumers, it's hard to know five years from now whether this really didn't improve. So for example, I would look at the question or somehow pose a question around costs and trying to figure out for some cross-section consumers how much of a barrier cost is today with a particular focus on both phase and deductiveness. And there'd be a way of getting some of that information and perhaps four or five years from now, they could look at it and say, gee, it looks like there's really a change of all of the systems on the clock. One that I always am flabbergasted that's never really dealt with, which should be understood, is the question of access, at least there are a lot of others that could lay out, access and waiting times. If you wanted to do this big survey, you could take everybody in this room right now and ask them questions. The first would be about hope, days and deductibles and the other would be about waiting, for everybody in the room, because I think you might find some interesting information that would help define where changes should happen for consumers and patients. It's hard to get that information either from hospitals or insurance companies that work for a variety of reasons that I won't admit to. So, and the third issue, I was really impressed about 30 years ago that I was in a very large gambling casino in Las Vegas. And it was very late at night and I was checking out, oh, it was a mental health conference. I'm not making that up. It was actually a mental health conference in the casino. It was a frontier, which I think has been knocked down through the rules. But the thing that was impressive to me was I was checking out, it was mayhem in the lobby with all kinds of people doing all kinds of things. But as I went to check it out, very late at night, they said in a very nice way, would you take five minutes and fill out this part about your satisfaction for your safety? And it seems to me we could do a whole lot of useful work to look at patients and consumers in our city. And yet, can't ask everybody, but there are ways of doing this that would give you a cross-section, because I don't think anybody in this room knows whether there's a high level of dissatisfaction or a low level. I don't, I mean, I guess. And it may depend on GFB, RLV, and others. That's it, it certainly may depend on a particular health situation. So those are three things. So I guess the question that I throw out is, how much of a consumer focus, a patient focus, is in the study or so much of this really from the institutions that provide both treatment and interventions? Should I go and answer? Sure. Okay, a couple of different things. So, because you had a lot to say, which was very provoking. So one is we didn't focus on patients or consumers in that sense, because this is not a healthcare study, right? It's what do we know about the health status of remonters and what should we be doing about it? And health access to healthcare will be one of the strategies, that's what we heard is necessary. But as Dr. Levine set up, we also know it's a small piece of overall health improvement. And so we didn't put an undue look into there because we have other ways in which we do look at patient satisfaction and access to care through our healthcare system. So that's not really what this one was about, but you will see that if you take a look at the document, and it's all posted online, in our state health assessment, when we looked at those subpopulations that we know have experienced inequities, one of the data points that we tried to look at across those patients or individuals as well as across the board for remonters, we looked at how many have accessed primary care in the last month, who has a primary care provider, and whether or not cost was an issue in terms of their accessing the care that they felt they needed. So we do have that data to see if cost is preventing people from engaging in their healthcare system. The question about satisfaction with their healthcare system is beyond this scope, but I know we have very good data that the health department has access to that's collected through the hospitals and submitted to our federal agencies and then posted on our hospital report cards. And that is something that we have, there are three different sections of the hospital report cards. Some are quality indicators, which include patient satisfaction, financial information of the hospitals, and then the results of the community health needs assessments. That's another way in which we can look at sort of that question of what are people experiencing in terms of their access to and experience with the healthcare system. On the broader level though, this question of how do you engage people and will they have a different perspective than we as institutions 100% agree with you. And I think that was what we were trying to say that this is why we're going to publish the state health improvement plan as preliminary strategies, recognizing that finalizing the strategies and developing a work plan for implementation is going to require us to have that absolute integration feedback loop with the people who are living in communities. So it's not institution driven, but it's actually driven by the people whose help will be improved if we make the changes. Because only they can talk to the experience of what it is like to try and improve health on their own. What's getting in the way for them that's beyond the access to healthcare. So we really are committed in that next phase to making sure those voices and that experience guides us because we don't have that from an institutional perspective. Okay, other public comment? Yes, Walter? Sure, so I can answer that very, very quickly. The purpose is that what we know is that the frustrations that many Vermonters have with their healthcare system in being able to access their system and being asked to improve their health. People who are living in the moment of having to deal with that have enough on their plates to have to navigate, to have the behaviors or have the access to the medications or their services or the lifestyle that they need to maintain their health. This plan is really trying to make it so that we change the conditions of people's lives and we're looking at opportunities for prevention so that the next set of folks will not have that same level of frustration and that same poor health outcome. So while there's a lot that our healthcare system can do now to help to make improvements for treating people who are already ill, this plan is really about prevention. So we have fewer people who are as ill as frustrated and who need the higher level of service because we've created communities and we've created systems and policies that support people in getting what they need so they don't experience ill health in the first place. So it's a very different paradigm. It's a very different approach. It's compliments the work that I think the Green Mountain Care Board is used to focusing on and has responsibility for in terms of healthcare delivery. This is not intended to be a healthcare delivery plan. It's really about a prevention plan and what we need to do to change the conditions in our communities and people's lives so they don't need that healthcare in the same way. Agreed and so I don't know if you were here for the presentation but when we spoke to people like yourself who were part of our advisory group and then we also looked at what the hospitals find when they talk to real human beings, if you ask people what is the problem that's getting in the way of being able to be healthy, they'll say lack of healthy food or access to food, transportation, housing and poverty. That's a driver. So we know that one of the primary determinants or drivers of poor health outcome is inability to maintain a stable income. And the systems and structures that are maybe contributing to that. So yes, agreed. Okay, other public comment? Yes. I think it is the perpetual challenge that you're asking for Dale and because we can't plan or implement strong programs without the individual voices of Vermonters, right? And yet being able to reach people, hear from them, understand them and translate that into policy and program is really challenging and particularly because a lot of people don't have the time to be as engaged because they're focused on just getting through everyday life and you know what that is, right? And so oftentimes the people that we need to hear from most are the folks who really have no time or the ability to stretch to bring those voices together. So we have to be really creative and use multiple types of strategies. And we historically have relied on surveys and we know now while they may give us the best quantitative data, they're very, very hard to get responses to now for a variety of reasons. And they only tell us the what, they don't tell us the why, right? We can describe what's happening but we don't really get that nuance. Well, why is it happening and what could be different? That can only happen in conversation and more of the qualitative research. And frankly, we don't invest in qualitative research to the same extent as we do in the quantitative. So I think we need sort of combination of approaches and sometimes we can get much more meaning from a very deliberative as you sort of said, you know, targeted way of engaging with people in conversation or a smaller population than we give credence to. And so I do think we can learn from one another and from that example that you gave on how we can do that better because otherwise we spend a lot of time and a lot of money and we miss the mark and we can't afford to do that. Okay, other public comment? Seeing none, is there any old business to come before the board? Seeing none, is there any new business to come before the board? Seeing none, is there a motion to adjourn? So moved. Second. It's been moved and seconded to adjourn. All those in favor signify by saying aye.