 Good morning and welcome to the Green Mountain Care Board. My name is Kevin Mullen chair of the board. Susan do you have an executive director's report. I guess I would just remind folks that we do have a meeting scheduled next Wednesday. The only agenda item is potential vote on the one care Vermont 21 budget. And as of this point in time we do not have anything scheduled the next week. Just keep an eye on our website for any calendar changes or additions. Thank you Susan. At this point then I'm going to turn the meeting over to Elena Barabee and Marissa Melamed to give us an update. Okay. Hello. Good morning everybody. I will share my screen. Let me know when you can see it. We can. Okay. So Elena Barabee Director of Health Systems Policy and I'm joined by Marissa Melamed who's our Associate Director of Health Care Policy and we're here to provide you an update on our staff recommendations given some additional information that we received from one care in response to our staff presentation that we gave on December 9th. So we'll go through background on the follow-up letter talk about what we learned. You know there are some updated recommendations and then go through next steps and open it up for questions and public comments. So if you'd like to look at these materials they're linked here. We issued a follow-up letter based on some of kind of the uncertainties and outstanding items that we discussed on the 9th. We sent that on the 11th and then one care submitted their responses to those questions on the 15th and provided some additional information and then we reviewed those materials and then you know updated our recommendations where appropriate. So if there are recommendations not in this presentation it means that we have not changed them from the December 9th presentation. The areas of follow-up topics included administrative expenses so to clarify uncertainties and justify growth and some of these expense line items so to get a better understanding of what was driving that growth. Sources and uses to clarify the nature and certainty of particular funding streams. This is an area that we hope to kind of get more standard templates and understanding as we go forward. So that was very helpful to talk through that more. The CPR program I believe board member Holmes had a question on kind of some of the discrepancies in nature of that funding stream so we did receive a response and felt that that clarified that response can be found in those in the one care materials but did not warrant any recommendations. So we won't go into detail there. But and then on in the fourth area was 2020 projected surplus and losses so looking for any updated projections and talking about justifying the accumulation of reserves to date. And so we have updated some of our recommendations on that front. And then we did have a question on some of the details of the contract negotiations which was determined confidential and you know I think that was resolved through those exchanges. And then in other topics raised by one care in their response that was not kind of a direct point of clarification from staff perspective was an opportunity to discuss the blueprint for health and SASH as it relates to the advanced shared savings. So we've included that in our presentation today. Learned you know so I think there's this idea that admin salaries are increasing at 18 percent. I think we just want to be clear what that 18 percent is attributed to. So really there's really only 2 percent salary increase which is about 3 percent of the 18 percent for the 1.4 million increase in salaries and then over the 2020 budget. So you know 8 percent of that is the impact of adding back vacancies that were kind of eliminated in the 2020 budget process after COVID. About $600,000 or 7 percent is the reinstatement of leadership compensation that was temporarily suspended again due to COVID the 2 percent salary increase and then now that explains all the variance associated with that line item. So we feel that we have a good idea of what's happening there. You know I think this would have been good for us to include in our last presentation but we just wanted to be clear that the admin budget is really a function not just of hospital dues but also you know it's half funded by Medicaid either through the Medicaid contract or DSR funding. There are 16 percent other which was you know we need to dig into that. I don't not sure exactly what the sources are at the other bucket but you know I think a quarter the point here is that a quarter of this administrative budget is uncertain if those DSR dollars are not acquired so just something to be aware of. So we updated our kind of outstanding uncertainties if you will. So I think the relationship between population health management and the admin ratio is still kind of an area that we need to work to better understand. You know I think we can really look at our guidance process and how we're collecting these data and talk about you know how do we get to better definitions of true admin versus operating costs. I think one care describes this in their letter back to the board and is an area of opportunity that we would like to pursue to really get a better understanding of how FTEs are fulfilling or kind of what value they're driving in you know health care in population health. So clarifying the population health how salaries you know align with different population health programs and initiatives payment reform and other provider support. We did kind of determine that the GMCB billback was overstated so we would expect that amount to come out of the budget. Again DSR funding is uncertain and the self management contract 261,000 of which shows up in the administrative budget that is also uncertain so we would recommend that the board you know could approve this budget conditional on those final steps. So this just gives you a sense of how admin expenses have grown over time relative to other other buckets of funding if you will or uses if you will. This is really a 38 percent increase over 2018 actuals 5 percent increase over 2019 actuals. It's a cut relative to the approved October 1 budget but an increase as compared to the June 16th budget and a 12 percent increase as compared to the projected 2020 budget amount. So I just wanted to in total that's how it kind of fits in with how this budget has grown over time. The ask is 1.16 million so this is a millions of dollars. Okay so the recommendation that we proposed on the 9th was to level fund to 2019 actuals. We proposed you know an alternate an alternate recommendation that you could conditionally approve the proposed budget with a reduction to the billback amount that was overstated and conditional on the receipt of the DSR funding and self management contract. So that would just require a revised budget submission for the board to review if those funding sources were not realized. Right over to Marissa. We'll leave us for here. Hi. Good morning. Thanks Elena. So as Elena said we did not ask any follow-up questions on the blueprint funding but one care did in their letter back to us respond to our recommendation to apply the inflationary factor to the blueprint funding as has been done in previous years. According to their response funding the blueprint with shared savings consumes a significant portion of the savings opportunity and expands the potential loss exposure which directly impacts ACO participating hospital financials and investments. They may make an anticipation of earning shared savings. The response the full response is posted and on this slide. We do recognize the challenge of ACO participating providers should during the contractual risk of non-ACO participants in the blueprint. However. Yep. Slide 13. We considered a priority that these programs continue to be funded because we know that they are curbing Medicare cost growth particularly as Medicare beneficiaries have continued to increase. We don't want to reduce the growth there. The statute in rule that we operate under requires the ACO to integrate and collaborate with the blueprint and the board's original vote to enter into the all-pair model agreement anticipated funding this program with the trend factor. So our recommendation is built on these three points. Swoop still on 13. We recognize that the asymmetrical risk to the ACO associated with investing the advanced shared savings in the blueprint for health in SASH. However receiving the advanced shared savings brings an additional eight million dollars plus into the state evaluations of the blueprint in SASH to adjust these programs generate savings and level funding the blueprint is effectively a rate cut to these programs as Medicare population benefiting from these programs is growing. Slide 14. We did update our recommendation slightly to say in 2021 one care must fund the SASH and blueprint for health DCMH and CHT investments in the amount of 8.4 million plus an inflationary factor of 3.5 percent totaling almost 8.7 this is consistent with the medical home community health team and SASH program payment designs that's approved by the agency of student services and that 3.5 percent is based on the Medicare benchmark growth target over the life of the agreement. Can turn it back to you Elena for reserves. You might be on mute Elena. Yep okay I got it all right. So thank you Chair Mullen. So for the reserves you know I think we just wanted to update some language here particularly. So I think we just wanted to clarify that the reserves were really about reporting to the board. So we updated our recommendation to include in future budget guidance reporting manual requirements for one care to report on any changes to its reserves and justification for any growth or disbursement including one care of Vermont's board approved amount and date of board approval. We'll maintain the recommendation that we would like an update on their final 2020 net income and subsequent use in the letter they indicated that there was no change to the expected zero dollar bottom line. So we'll kind of just you know continue to ask that they keep us apprised if there are any changes there. And then we'll keep and update the 2020 recommendation around notification to the board within 15 days of use of any reserve amounts. But you know because this reserve amount was growing and we didn't know about it I you know we eliminated the four million dollar kind of amount there just to indicate that you know for any reserve use of any reserve we would expect notification to the board and that we made an adjustment here which I have to double check but I think was maybe already part of a revised recommendation in a budget amendment but to remove the engaging in hospital sustainability planning now that all hospitals are engaging in sustainability planning so that should kind of expand the use or the pool that these reserves could be used for. In terms of next steps you know we expect the potential board vote to happen on the 23rd when we come before the board on the 23rd we will kind of organize our recommendations and indicate which items would exist in the budget order condition which items would we would expect to see in a reporting manual and then which recommendations we would kind of work to incorporate into 2022 budget guidance. This will allow us to issue a budget order in early 2021 if the board votes to approve the budget and then we would still continue to you know look forward to our revised budget once all the contracts are executed and we have the final attribution numbers. So that will that concludes our presentation for today. We are happy to open it up for any questions. Chair Mullen or as you. Thank you Elena and I know that one member of the board has an emergency situation that will require an early leave so in order to try to speed things up I'm wondering if it might be best to go out of order and not start with board questions but go immediately to Vicki Loner at OneCare to try to address some of the issues that there may be misconceptions on and get those out of the way. So for example Vicki some of the questions might be is anyone other than in a low level position going to receive a 2 percent increase in pay. What maybe you could address the reserve situation and further on the blueprint in SASH I think if you could really detail what you're thinking on that issue I think it would help to move things along quickly. Great thank you so much Chair Mullen. And first I want to thank the staff at the Green Mountain Care Board. They've been working really hard over the last couple days with our staff at OneCare Vermont to seek clarity on some of the outstanding questions and to really come to a common understanding about our budget and the intent. We know that this is pretty complex information and even in the best of times when we can sit around a room together and really dig into the details having to do this remotely during a pandemic when I think everybody's stress levels are higher than normal can create some challenges in of itself. So I just want to take a moment to thank them for their hard work over over this period of time. Thanks very much for being able to address some of the questions. I do want to say that OneCare does support the revised operations to come back in the spring because we do know that there is some uncertainty around some of the programs such as the DSR programs and the self-management. And of course we will adjust for the bill back when that that number is known. I think we're both in a position of kind of uncertainty on what that number would be. So I just want to put that out there as something that OneCare would intend to do. So I very much would support approving as is conditionally and coming back in the spring once we have more information. Chairman Mullen in terms of your question around the 2 percent the 2 percent is across the board so every employee within OneCare Vermont would receive a 2 percent increase and that's standard with all of our employment arrangements which are which are through the University of Vermont Medical Center. So that is the the first question. In terms of the reserves we did intend to keep our reserves level going into next year. And while we do understand that there is reduced overall total cost of care risk because of the pandemic there's other risks that OneCare could incur such as if a hospital was not able to repay the all-inclusive population-based payment if there were some overpayment that is something that the federal government would come to OneCare Vermont for and not necessarily the individual hospitals because the ACO is the entity that would be responsible to repatriate those those funds in any overpayments. There's also the situation and let's hope this doesn't ever happen where a payer is unable to make a payment to OneCare Vermont or if hospitals are unable to make the level of investments that they're making in population health management. So if we were to think about this as day's cash on hand it's it's very small in fact. So we believe that we're kind of at the minimum necessary right now for the reserves and do agree with the language as we're in that we would of course come to the board if we needed to leverage those reserves for for any particular reason. And then the last thing on the blueprint I want to say that I appreciate that the staff and the board realized that the way that the blueprint is included in the ACO contract does make for some asymmetry for those hospitals that are taking on the full financial risk for this particular program as well as continuing to make investments in their communities that are far reaching beyond their own organization and include other programs. I just wanted to be clear because there's always some nuance in this. OneCare has included the inflationary rate into our overall budget but our intent was to only apply that inflationary rate to those hospitals that are participating in the Medicare program and who are also the hospital administrators for the blueprint program. So this would create a small incentive for those providers that are fully participating in healthcare reform efforts and I do believe that is in line with HHS's all-pair model improvement plan to say that we want to create some incentives for participation and value-based care while at the same time still funding those providers who are either not at all participating in healthcare reform activities at any level and or those providers who are starting to participate but haven't yet been able to participate fully in things like Medicare where the risk and reward as well as the overall operational challenges and questions especially for critical access hospitals are still really an open switch. So I didn't want this committee to think that we were leaving federal dollars on the table. Indeed we were just trying to create some modest incentives for those hospitals that are that are participating in Medicare and who are also fully participating in the blueprint for a health program. And I would encourage if we could to make sure that we maximize I know it's asterisk at 3.5 but really maximize that federal inflationary rate to make sure that the providers have their resources and ability to really continue to move forward in a pretty ambitious goal that we have for the state. So that would conclude my comments but I'm also happy to take any questions and I thank the board and the staff for their time and the ability to provide some additional clarification. Super thank you Vicki. And I'm going to start the board questioning in reverse alphabetical order and Maureen knowing that you're under a time constraint. If you also have a question that you wish to direct to Vicki in addition to our staff I'll allow that to happen too. Sure I actually don't have any additional questions. I thought the presentation was was very thorough and addressed the questions that were outstanding and I'm comfortable with what the staff is recommending. Thank you Maureen. Tom. Thank you. I have a couple of questions on little some more clarity on the on the salaries. I'm looking at the appendix 6.2 which is the income statement and for 2020 budget the salary amount was 8.352 million and for 2020 projected obviously incorporating the COVID period it's 8.344 million which is just a decrease of 11,988 bucks. And so I'm just trying to reconcile that it looks like you came in on budget or you project to come in on budget in 2020 and but yet in the slides are these references to your vacancies that were held open and leadership compensation that wasn't paid and that you're kind of building that back in in your 2021 budget which adds up to the 1.47 million dollars. So I feel like I'm missing something. It looks like 2020 projected versus 2020 budget is pretty much on track. And so I'm trying to figure out where we would see in the 2020 budget these vacancy savings and leadership compensation retentions, et cetera. I don't know if staff wants to take that from the Green Mountain Care Board or. Well, I just want to say I think I don't know that's the big year Elena but the if you're referring Tom back to the October 1 submitted that's actually not shown in this table 6.2 so that that is not showing the original submitted 2020. We can work with you Tom to point you to the missing information. Well, I just like to see it because the last operating income statement I have that's that's what it shows. Yeah, something that I keep in mind when looking at the you know the impact of the administrative expenses is that when we went through the hospital budget process this year on the revenue side, we allowed a overall a 2.7% increase in that patient revenue FPP across all 14 hospitals. And if you take out the University of Vermont Medical Center that's act and just look at the remaining 13 hospitals. It's a four tenths of a 1% increase. And so, you know, my observation is that we are in tough times and I think that the staff recommendation makes sense in that context. It's obviously not a perfect plan, but you know, from maybe the ACO's perspective, but that these are tough times and and the hospitals which are paying the dues came in in their budget process at very meager increases and almost level funding when you take out the University of Vermont Medical Center. So level funding makes sense to me in a in a broad broad context. I also kind of want to ask a question or at least the paint and expectation that relative to the blueprint and sash and the money there. Last year, during these hearings, I raised the issue of the benchmark plan and whether or not that benchmark plan was aligned with the population health goals that we have in the all pair model and that the ACO, to a great extent, is the point of the spear to leave the charge here. And, you know, just kind of looking at the you know, at the twenty twenty one approved premium levels for the QHP plan, which is founded on the benchmark plan. You know, we have over five hundred and forty million dollars of premium between MVP and Blue Cross Blue Shield coming in. Yet the benchmark plan hasn't been revised since 2012. It doesn't easily allow for pre diabetes treatments or benefits and and obviously for twenty twenty one, that's not something that that can happen because, you know, the the horse is out of the barn there. But for twenty twenty two, it does seem to me in the context of rearranging the self management programs, which the blueprint does operate or sponsor the best pre diabetes program that the CDC can remember that in the realignments here, looking at the benchmark plan for twenty twenty two may be a source of finding revenues to help the blueprint you know, just because they become a provider for pre a pre diabetes. So I'm I'm urging the ACO to take a look at the benchmark plan, take a look at their population health and quality goals and objectives and come back to the board and say these are well aligned and there's nothing to be gained there or these are not well aligned. And here are some opportunities that that the ACO and the insurers and Diva can work on to better align the application of these premiums, which is a lot of money toward an approach that is consistent with our population health goals. So that's in terms of the topics that we're discussing today. Those are my my questions and my comments. Thank you. Tom, I did notice that Tom Boris had his hand raised and I'm assuming that may be to answer your earlier question. Tom Boris, is that why your hand is raised? Yes, it is. Thanks. I can speak to the twenty twenty projection comment a little bit, if that's helpful. So going back down memory lane here, we built the revised twenty twenty budget in the May, early June period. And it certainly felt like this guy was falling at that point in time. So what we did was build in every single savings aspect that we could at that point. And basically that meant we had a budget that was completed sometime in June. And that became basically also our best projection of the year. So those were done concurrently. That's why you see a lot of similarities between the budget, revised budget we submitted and our projection because they were actually done at the same point in time. We are now in the process now that the cyber event is slowly allowing us to get some resources back, catching up on a couple couple of monthly closes and updating our twenty twenty projections. I can say I don't expect any material shifts, maybe some timing issues, but nothing of substance to note here. But that's why the twenty twenty projection and budget looks so similar. Thank you for that, Tom. So do you have a sounds like you don't have a number for salaries for a for a twenty twenty projection? No, I'm a hip pocket, but I do know that we're tracking quite close to budget pretty much across the board. So you are tracking close to budget in twenty twenty projection relative to the twenty twenty approved budget. That's correct. And did the twenty twenty approved budget include the leadership compensation, et cetera? It did. All of the cuts that we put into place in twenty twenty leadership comp, the hiring freeze was, et cetera, was all built into that revised twenty twenty budget model already. That's why when you compare that revised model to twenty twenty one, it looks like there's an increase. We're really just trying to restore those cuts and also give one care the resources it needs, because from a staffing perspective, the amount that we lived with in twenty twenty was not sufficient for us to keep moving forward and continue to grow these programs. OK, that's helpful. Thank you. Thank you, Tom, and thank you, Tom. So with that, we'll go to board member Robin launch. Thanks, Kevin. So I got a couple of comments. Um, that I wanted to make the I'm going to focus first on the blueprint and sash programs. I did a little trip down memory lane and looked at the blueprint statute since we last met. And I would like to make a suggested change to the staff recommendation to clarify things a little bit. Um, and so in 18 VSA 702 D1C, the blueprint for health is required. It's a shall to include a model for uniform payment for health services by health insurers, Medicaid, Medicare and other entities that encourage the use of medical home and community health teams. And so based on that statutory, programmatic directive to the blueprint, I like the part of the recommendation that allows for the growth in the blueprint, medical home and CHT dollars to for the ACO and AHS to work out how that is distributed. Because I think the statute intends that the blueprint be a multi payer program with payment model and programmatic alignment across the different payment sources. So I do like that part. But I would personally like to add some clarity around sash. Sash started as a blueprint program. However, it started well after the statutory enactment. So it's really the statute is silent on sash. I feel like the intent behind the all payer model agreement and certainly the articulated promise, if you will, to that program was that there would be a growth trend for that program over time. And that was one of the benefits that the state was seeing from this new agreement with the feds. However, I think, you know, since the funding stream now comes through Medicare through the ACO program and we are stepping into the shoes of Medicare in regulating the growth in that payment. I think it is appropriate for us to be clear in that in our order that the expectation is that the the budget for sash is the budget from last year trended forward with 3.5%. So I think that that would require a little bit of a tweak or clarification and the staff recommendation when it's translated into budget order language. But I just wanted to put that out there now so that everybody else on the board would have a chance to think about it and certainly would welcome Vicki's comments. And what I would just say Vicki is that it was not clear in your budget submission that your proposal was to trend the money but use it for in a different way. That was not at all clear. In fact, I feel like I am hearing it for the first time clearly today, three business days before we're voting. So particularly with these programs I feel an obligation to delve a little bit deeper because we are stepping into the shoes of Medicare so we are in a different position than we are doing when doing our overall budget review as the regulator under the state statute. So I'll pause there to see if Vicki wanted to respond. Certainly you don't have to Vicki but I I'll just pause there and then I'll make my other comment. Sure. Thanks Robin. I think that this is all really nuanced and I think we're finally just getting to some common understanding of the blueprint and how that works. So certainly this was a good opportunity for us to be able to get in a similar position. We do still stand pretty firmly that we believe that those incentives should go to those hospitals that are participating in both the Medicare and the Blueprint programs. We are funding about half of the funding of the 8.5 goes to SASH already and only half of those communities are actually participating in the Medicare program. So their costs although they might be driving down state costs they are not driving down costs for the ACO. So not directly participating in the Medicare program. So if if we have to if the ACO has to continue seeing that there is this asymmetrical risk providing the same incentive regardless of whether or not you're participating in payment reform it doesn't provide much of an incentive for hospitals to continue to participate and take on the risk in these programs. So I think it's a modest incentive but I think it's the right incentive and it provides the right directionality moving forward of having you know to consider participating in these programs moving forward. We're certainly not cutting their funding. We haven't seen anything that the program is growing but it is keeping it flat for the number of participants they currently have right now. And just if I could interject Robin for a second and put Susan Barrett on the spot. We did reach out to AHS and ask them for some feedback on this topic. And Susan do we know when we will get that feedback. I anticipate we'll get something from AHS before you make your decision next Wednesday. I know they're they're very busy with the COVID issues so I think we're doing our best to turn that around. But I expect to hear maybe early next week. Thank you. Sorry about that Robin I just wanted to. No problem. That's helpful. That's great. I welcome their feedback. And then the the other place I wanted to make a comment is on the admin expense growth and I appreciate and am supportive of reestablishing the the funding for the vacancies. And quite frankly like my general approach in hospital budgets and our other regulatory is like it really does not make sense to get into like kind of that level of line item up and down because especially in this budget where so much of it is driven by the payer contracts which are not finalized in time for us to review them as at this part at this point in the budget process. I would say that I did find the messaging somewhat inconsistent because certainly I appreciate and supported reducing hospital dues and adjusting risk in the programs to to reflect the fact that we are in the middle of a pandemic. However it seems with the admin budget then the messaging gets lost and it says though we're no longer in the middle of a pandemic. So I just want to make that comment that I think you know to the staff's point a big chunk of the admin budget revenue is uncertain and so it does make sense that we're kind of looking at the best case scenario and that we revisit that in the spring given the way this process flows every year where we never really know what the revenue is going to look like until after the payer contracts are finalized which happens after we vote at this point. So that was just the other comment I wanted to make. Thank you Robin. Jessica. Thanks Kevin. I just had a clarifying question. I want to thank the staff for all of the work on the recommendations and all of that. I'm comfortable with them. But the one question actually was raised with Vicki's point. The original submission requested level funding for you know blueprint sash advanced savings that bucket of dollars but if I understood Vicki's point just now is that there seem to have been a request and maybe I'm wrong about this Vicki to maximize the federal funding was that a request to go higher than the 3.5 you know that's been proposed by the staff now. So actually asking for a clarification on that point particularly given the asymmetric risk therein and a better understanding of really what the what a pragmatic upper limit might be from the staff maybe perspective. But maybe first to Vicki if I want to understand that. Yeah absolutely Jessica we want to make sure that we maximize the federal trend that's available to us and I might call on Tom I believe based on the way the contract is written with the state that we team Vermont would be eligible for up to a 4.3 percent increase. Do I have that number right. Yeah and I can just add a little bit of color that that number is sourced from the the Medicare Advantage United States per capita cost growth forecast that the CMS obviously the actuary puts out Sarah Lindbergh is your resident expert on it she knows this stuff well but that is outlined in the Vermont all-payer model agreement as kind of a cap or an upper limit on the trend that's allowable under this program and when we built the and submitted the budget in October we included that full trend on the entire total cost of care which includes the MAP CP adjustment that is the kind of funding opportunity for the blueprint dollars. Okay so you would be seeking with B4.3 instead of the 3.5 on those blueprint dollars despite the fact that there's that risk that you did talk about in your response and the asymmetrical downside risk that's something that you're willing to live with now with the 4.3. Is that accurate. The way that I think of it is if we as Vermont and OneCare advocates for this that we'd like to get the 4.3 into the state as funding for the participants in this program. So that that I think is one underlying piece that's important to be clear on the component that's underneath it that's probably more nuanced is that in our budget proposal we propose level funding the blueprint expenses going out the door and using the Delta the variance between the dollars coming in on the MAP CP adjustment versus the dollars going out as an incentive for the hospital participants. It gets complicated in the way that that accrues and the way the dollars flow in the system but the net difference between the expense and what we bring in under the target is an incentive small but important incentive for those participants who have committed to participating in the Medicare program. So would they still be blueprint and sash dollars just variably paid to those participants who are participating in Medicare but they're still blueprint and sash dollars just variably paid depending upon whether you're participating in the Medicare component. I think that they could be considered that way. It's it's really whether we paid them out as blueprint and it helps in their overall economics at the end of the year or we use it to help balance their settlement to at least offset to some degree the asymmetry that that chart showed is fine to me but that that's the conceptual approach here is that we're trying to help protect the financials for these participants in the Medicare program. Can I ask a question Chairman Mellon. Yes. So I mean I think this is new information to staff and I think that we would need to understand where this because you proposed to level fund the blueprint in your submission that baking in this 4.3 must show up somewhere else that was not taken into consideration nor was it communicated clearly to staff. So I think we would need to know where that shows up on your income statement to understand what the impact would be on your budget of taking that 4.3 out. I mean because our recommendation is to apply the growth and keep it in the blueprint and the sash program. So I mean and I think getting some clarity on if it is variable payment like Board Member Holmes was asking if it stays at the blueprint or sash or if so does that mean that they get in effect a higher variable payment than an amount because the number of providers is fewer or is it that you're taking that money and putting it elsewhere in the budget. Because I think the math there's still some uncertainty there. So Elena if I could just be simple about this and then Tom can get more detailed if needed. It's always included the 4.35 but the 4. That percentage increase is going directly to the hospitals who are also the administrators of the blueprint for health. So it's going directly to them. So we're not spreading it to sash or other patient centered medical homes going directly to the hospitals. So let me phrase it a little bit differently Vicki or Tom following up on both Jess and Elena. What guarantees do we have that the hospitals will use that increase on health care reform efforts and besides blueprint and sash what would be the spectrum of possibilities. Well to the first question the way that that essentially works is by getting the trend on the map CP adjustment and the entire target which is Vicki's correct. It wasn't when we built the budget we included the full 4.35 percent trend on the entire Medicare target which is inclusive of the claims components for the ESRD and the non-ESRD cohorts and the map CP adjustment. On the expense what is an actual expense for one care are the blueprint costs. We write checks every quarter for sash community health teams PCMH. What's tricky in there is the difference between those materializes that settlement. It helps the final settlement of the program when we net out with Medicare because we have to account for that map CP adjustment at the time of settlement particularly if we got an advance of the cash. And it helps offset costs or increases the amount that the potential participants can receive in shared savings. I know it's technical it's a this is the most complicated aspect of the one care budget which is why we're having this conversation today. It's very difficult to explain. But so let's be less technical and let me try to rephrase it a different way. Is there a possibility that the increase that went out would would just be kept to reduce dues rather than be used on reform efforts. I mean I would think that would be counterproductive to trying to bring down total cost of care in order to maximize your potential savings opportunity. So with any of these reform efforts the hospitals providers FQHCs need to do everything they can to really maximize those care coordination and prevention efforts. We of course can't dictate you know I think you'd find across the board that blueprint dollars are probably used in very different ways from one practice to another. But it would hurt the hospitals who are taking risks if they're not really maximizing those prevention and care coordination efforts. What prohibits you from dictating to make sure that the blueprint dollars are specifically used for population health and reform activities. I think the challenge chair Mullen is that the blueprint for health is not with under the control of one care Vermont. So this is a state as Robin indicated this is a state run program and they kind of dictate the terms and requirements and evaluation of the programs. This is something that sits on our contract which is we're having this discussion today really does complicate things when not everybody is actually participating in the Medicare program. So I would say this is fully within the control of the Agency of Human Services. OK thank you. Go ahead Jess I'm sorry to interrupt. No I appreciated those questions. That that was my only question so thank you. OK. Can I just make one more comment. Absolutely. You know I am open to having a conversation about how to better align the incentives between the ACO program and the blueprint program. However I would be a lot more open to it if it if you had if we had this conversation as part of your budget discussion and not three days before business days before the vote. I'll just tell you it's like it's too late in my mind to try and really fully understand and get the necessary stakeholder impact to understand this proposal which was not clearly made at the budget presentation. So you know I'm in future I'm I'm open to having a more robust conversation about this but it to me like it just reinforces that our order needs to be clear on what goes out both the trend for what comes in and the amount that goes out at least for SASH and as I said I'm willing to leave it up to AHS as you know the person the agency responsible for the blueprint to work out how the remaining dollars are used between the ACO and AHS. So it just sort of reinforces my position to be honest because I don't feel like we can really do a good job on this topic at this late time. So I appreciate that Robin and I would just say that I'm not feeling the pressure that if we don't have all the necessary information to actually vote next Wednesday I think that we need to get all the information and make the right decisions. And so I would hope that we do have enough time to completely dissect this this issue and come to a firm decision by next Wednesday. But if we don't I'm also not feeling pressured to make that decision next Wednesday. So that's just one board member. Other members of the board if not I will say that we're way ahead of where I thought we would be at this point in time but I'm going to open it up to a public comment. Is there anyone who wishes to make a public comment on the ACO budget discussion. Another very quiet day maybe Fridays are the day to have meetings I don't know. With that then I guess is there any old business to come before the board. Chair Malin this is Susan can I just add one thing that I very minor and the agenda for next week also has a potential vote for the Medicare benchmark. I failed to say that earlier so. Thank you for clarifying that. And not hearing any old business before I go to new business I neglected to appropriately thank staff Elena and Marissa and others working behind the scenes on this. I know this has been a very challenging and difficult process but at the end of the day we need to dig deep and we need to fully understand exactly what we could possibly be approving. And so your efforts are greatly greatly appreciated by all members of the board. And we know it's not easy working those long hours especially during the holiday time. But if there's any advantage to a COVID year it's that sometimes it seems like work takes our mind off of other things. So we're very very thankful to you Elena and thank you Marissa. And if you could extend our thanks to the other members who have been working with you we are deeply grateful. With that is there any new business to come before the board. Tom there was a little bit of noise coming from your way. Was that a new business I guess. I was preparing to make a motion to adjourn but. Well you may proceed Mr. Pellum. We'll ask the question Mr. Chair. Is there a motion to adjourn. Yes there is. I so move. Is there a second. Second. You can second. It's been moved and seconded to adjourn. All those in favor signify by saying aye. Aye. Aye. Those opposed signify by saying nay. Thank you everyone and I know that the one care team and staff will continue to really hammer down the final understanding so that we all can accurately and confidently know what we are voting on before we vote on it. So thank you everyone and have a great weekend.